IS THE OFFICIAL NEWSMAGAZINE OF THE CONGRESS OF NEUROLOGICAL SURGEONS
summer 2013
Golden
Years
How Neurosurgeons
are addressing an aging
population.
4
Elderly Issues:
<
>
Society Getting
Older
<
23
>
ELECTRONIC HEALTH
RECORD (EHR),
NEUROSURGEONS
DEFINE
MEANINGFUL USE
Summer, 2013
Volume 14, Number 3
EDITOR:
James S. Harrop, MD, FACS
Co-Editor
Michael Y. Wang, MD, FACS
Associate Editors:
Steven N. Kalkanis, MD
Catherine A. Mazzola, MD
EDITORIAL BOARD:
Aviva Abosch, MD
Edward C. Benzel, MD
Nicholas M. Boulis, MD
L. Fernando Gonzalez, MD
Costas G. Hadjipanayis, MD, PhD
Zachary N. Litvack, MD
Andre Machado, MD, PhD
Srinivas K. Prasad, MD
Charles J. Prestigiacomo, MD
Alfredo Quinones-Hinojosa, MD
Ann M. Ritter, MD
Jason M. Schwalb, MD
Daniel M. Sciubba, MD
Ashwini D. Sharan, MD
Gary R. Simonds, MD
Jamie S. Ullman, MD, FACS
STAFF EDITORs:
April L. Booze
Christina V. Orda
DESIGNER:
Westbound Publications
PUBLISHER:
Jason Pointe
Senior Production Associate:
Lisa Bowling
CONGRESS OF NEUROLOGICAL SURGEONS
2012-2013 OFFICERS
PRESIDENT:
Ali R. Rezai, MD
PRESIDENT ELECT:
Daniel K. Resnick, MD
VICE-PRESIDENT:
Jamie S. Ullman, MD, FACS
SECRETARY:
Alan M. Scarrow, MD, JD
TREASURER:
Russell R. Lonser, MD
PAST-PRESIDENT:
Christopher E. Wolfla, MD, FAANS
CONGRESS OF NEUROLOGICAL SURGEONS MISSION STATEMENT:
The Congress of Neurological Surgeons exists to enhance health and
improve lives worldwide through the advancement of education and
scientific exchange.
Congress Quarterly is the official newsmagazine of the Congress
of Neurological Surgeons, located at 10 North Martingale Road,
Suite 190, Schaumburg, IL 60173. Members of the Congress
of Neurological Surgeons may call 847.240.2500 with inquiries
regarding their subscription to Congress Quarterly. Congress
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© 2013 by the Congress of Neurological Surgeons. No part of this
publication may be reproduced in any form or language without written
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EDITOR’S NOTE
In this issue of Congress Quarterly (cnsq), we take a
brief look at the most rapidly advancing portion of the
neurosurgeons’ practice, geriatric or elderly patients. This
issue is dedicated to the challenges we as neurosurgeons and
our patients face. Dr. Joseph Cheng provides an overview of
the situation in Elderly Issues: Our Society Getting Older.
Dr. Matthew McGirt and Dr. Saniya Godil detail a difficult
question of aging, cost, and quality in their article Health
Care Cost, Quality, and the Aging Population: A Challenge
to the Neurosurgery Value Proposition.
The articles then shift their focus into disease-specific
James S. Harrop,
areas and the aging population. The first area covered
MD, FACS
is spinal disorders. Again, Dr. Matthew McGirt and Dr.
Saniya Godil provide another interesting and detailed article
on Prolonged Medical Management of Lumbar Spine Disorders in the Elderly:
Questioning its Value, an Argument for Surgery. I discuss Spine Surgery in an
Increasingly Aging Population. Lastly, Dr. Michael Wang discusses the challenges of
Spinal Deformities in an Aging Population.
There are also numerous intracranial issues facing the elderly or geriatric
population. Dr. Nicholas Ferraro, Dr. Ryan Kitagawa, and Dr. M. Ross Bullock
discuss Traumatic Brain Injury in the Elderly. The Jefferson Hospital Neurovascular
Team led by Dr. Robert Starke reviews Management of Cerebral Aneurysms in the
Elderly, and Dr. Christopher Farrell and Dr. Steven Kalkanis discuss the decisions
of when it is appropriate to treat in an article entitled Brain Tumor Management in
the Elderly – Too Old to Treat? Dr. Jason Schwalb and Dr. Rhonna Shatz discuss
the increased and more common problem of Normal Pressure Hydrocephalus:
A Multidisciplinary Approach. Lastly, Dr. David Krieger and Dr. L. Fernando
Gonzalez review the carotid artery disease in the article Is it CAS or CEA That is
Not Cost-Effective?
In addition, we are fortunate that this issue has numerous featured articles.
Dr. Deborah Benzil and Dr. Srinivas Prasad review the Electronic Health Record
(EHR), Neurosurgeons Define Meaningful Use. Also, discussing government health
quality issues, Dr. Vincent Traynelis provides an article from the American Board
of Neurological Surgery, the Maintenance of Certificate process and PQRS. Katie
Orrico and Dr. Ann Stroink provide an overview of the numerous neurosurgeons
that are involved in American Medical Association (AMA). Dr. Paul Kaloostian, Dr.
Han Chen, and Dr. Martina Stippler review operative documentation for residency
training. Lastly, Dr. Duane Gainsburg provides his outlook on aging in his article
Locum Tenens: My Solution to Physician Burnout.
As always, we hope that you find this issue informative and interesting and if
there is any way we can facilitate your needs, please do not hesitate to contact us at
[email protected].
CONTENTS
12
Editor’s Note
James S. Harrop
2 President’s Message
Ali R. Rezai
3 CEO Update
David A. Westman
The Golden Years
4 Elderly Issues: Our Society
Getting Older
Joseph S. Cheng
6 Healthcare Cost, Quality,
and the Aging Population: A
Challenge to the Neurosurgery
Value Proposition
Matthew J. McGirt, Saniya S. Godil
8 Prolonged Medical
Management of Lumbar
Spine Disorders in the Elderly:
Questioning its Value, an
Argument for Surgery
Matthew J. McGirt, Saniya S. Godil
10 Spine Surgery in an Increasingly
Aging Population
James S. Harrop
19
14 Traumatic Brain Injury in the
Elderly
Nicholas Ferraro, Ryan Kitagawa,
M. Ross Bullock
16 Management of Cerebral
Aneurysms in the Elderly
Robert M. Starke, L. Fernando
Gonzalez, Pascal M. Jabbour,
Stavropoula I. Tjoumakaris,
Robert H. Rosenwasser,
Aaron S. Dumont, MD
18 Is it CAS or CEA That is Not
Cost-Effective?
26
25 Neurosurgeons Providing a
Strong Voice at the AMA
Katie O. Orrico, Ann Stroink
27 Locum Tenens, My Solution to
Physician Burnout
Duane Gainsburg
28 A Retrospective Study of a
Novel Operative Documentation
Education Program with an
Emphasis on Coding: A New
Addition to Modern Neurosurgery
Residency Training?
Paul E. Kaloostian, Han Chen,
Martina Stippler
David Krieger, L. Fernando Gonzalez
19 Brain Tumor Management in the
Elderly – Too Old to Treat?
30 MOC: PQRS
22 Normal Pressure Hydrocephalus:
A Multidisciplinary Approach
Inside the CNS
Vincent Traynelis
Christopher Farrell, Steven N. Kalkanis
Jason M. Schwalb, Rhonna Shatz
Featured Articles
23 Electronic Health Record
(EHR), Neurosurgeons Define
Meaningful Use
Deborah L. Benzil, Srinivas Prasad
31 Washington Update: Medicare
Physician Pay Cuts Take Effect
on April 1, 2013
Katie O. Orrico
CNSQ BACK PAGE
Images in Neurosurgery
11 Spinal Deformities in an
Aging Population
Michael Y. Wang
Summer 2013 1
PRESIDENT’S MESSAGE
Fostering International
Partnerships
Ali R. Rezai, MD
President, Congress of
Neurological Surgeons
S
ince the inception of the Congress of
Neurological Surgeons in 1951, we have
strived to foster neurosurgical education
and advance our specialty by collaborating and
partnering with our international colleagues.
Now, 60 years later, we are more committed
than ever to our mission of the advancement of
education and scientific exchange and enhancing
health and improving lives worldwide.
Over the past decade, the CNS has significantly expanded its international society
partnerships and exchange of activities and
educational programs by jointly participating
in each other’s Annual Meetings, events and
activities. This scientific, cultural and social
exchange has led to sustained relationships,
collaboration and valuable friendships between CNS members and our colleagues from
the Italian (SiNCH), European (EANS), German
(DGNC), Japanese (JCNS), Brazilian (SBN), Indian (NSI), Korean (KNS), Spanish (SENEC),
Central European (CENS) societies and others.
This year’s Annual Meeting partner society
is the Chinese Neurosurgical Society. Leaders
from both societies have been participating in
the development of our joint meeting and its scientific programs. Additionally, this year we are
pleased to welcome three honored guests, Dr. L.
Nelson Hopkins III, Dr. Johannes Schramm and
Dr. Andrew Kaye. Dr. Schramm and Dr. Kaye
will join us to share their leadership and worldrenowned expertise from Germany and Australia,
respectively. This comes full circle to our humble
beginnings, when our first two Annual Meeting
honored guests were internationally-renowned
neurosurgeons, Herbert Olivecrona from Sweden
and Sir Geoffrey Jefferson from Britain.
The CNS is advancing global neurosurgical
education with our comprehensive and innovative simulation (CNS-SIM) platform. Simulation training is an increasingly important
requirement for learning and certification in
CNS International Accomplishments
• 1,155 international members representing over 100
countries
• 1,800 international submissions in 2012 to
Neurosurgery
• Provided SANS Lifelong Learning licenses to two
underdeveloped countries
• Launch of the CNS SIM at three international
partner sites
• Partnering with the WFNS to donate neurosurgical
equipment to underdeveloped countries
• Partnering with the WFNS in 2012 to assist in meeting
management of their Bi-annual Spine meeting
• Annually fund $25,000 in travel stipends for our
international partners
• Exchange faculty for international society meetings
• Reciprocal partnership arrangement with EANS
2
medical specialties, and the CNS is providing
a leadership role in defining and operationalizing the use of simulators in neurosurgery.
Our comprehensive platform utilizes the latest
in simulation technology in conjunction with
a standardized curriculum, task validation
and prospective objective assessments. The
CNS-SIM includes web-based, virtual reality,
haptic feedback devices, as well as physical models for the spine, skull base, trauma,
vascular, endovascular and functional subspecialties. This platform is being utilized in
partnership with the EANS resident course in
summer 2013 in Prague, in Tel Aviv and also
in December 2013 at the Annual Meeting of
NSI in Mumbai, India. Multiple additional partnerships utilizing CNS-SIM are being planned
with our international colleagues and partner
societies across the world.
The CNS has always strongly emphasized
the education of residents. Each year, we
offer the highly successful senior resident
3D Anatomy Course. The CNS and the EANS
send faculty and US residents to two surgical
dissection-based courses in Europe, while inviting European residents to participate in our
3D course in the US.
The CNS is committed to developing a comprehensive international strategy, including
learning more about practice and research environments for neurosurgeons in various countries and identifying initiatives and methods to
engage with global and regional neurosurgical
societies. We believe that by continuing to
build and foster these relationships, the CNS
will continue to be an important organization
of value for neurosurgeons worldwide.
We are honored to partner with our international colleagues and societies to mutually
benefit each other’s missions, and look forward to even better connectivity, cooperation
and collegial interactions as we collaborate to
advance our specialty. <
WWW.CNS.ORG
CEO Update
David A. Westman, MBA,
CPA, CAE
CEO, Congress of Neurological
Surgeons
A
s I approach my one-year anniversary at
the CNS, I want to take a moment to say
THANK YOU! It has been an honor and
privilege to work with and for an organization
that has such a vibrant Executive Committee
and other volunteer leaders, members who
serve such a vital purpose in our society, and a
contingent of dedicated staff in our Schaumburg
Headquarters’ office who work tirelessly on
behalf of all of you.
I would also like to provide a few key highlights of what the CNS is focusing on for you,
our members as we move forward.
Renewed International Focus – As Dr.
Rezai noted in his President’s Message (see
previous page), the CNS is re-engaging and putting a renewed emphasis on our international
partners and opportunities for collaboration
and growth. We are exploring opportunities to
expand our international educational offerings
in support of international neurosurgical development. As the global leader in education, this
is mission-critical.
Increased Engagement with Corporate
Partners – We are doing more than we ever
have to truly listen to our partners and construct win-win opportunities for their engagement with and support of the CNS.
Finalizing a Strategic Plan – One of my
priorities since arriving at the CNS has been
working with Dr. Rezai, CNS Executive Committee members and our Senior Management
WWW.CNS.ORG > This (strategic) plan will provide a vision
and focus to guide the CNS in identifying
the most relevant strategic priorities for
our members and other key stakeholders, as
well as expanding our product and service
offerings to effectively meet your needs. <
Team to construct our 2014-2016 strategic
plan. This plan will provide a vision and focus
to guide the CNS in identifying the most relevant strategic priorities for our members and
other key stakeholders, as well as expanding
our product and service offerings to effectively
meet your needs. This plan will be unveiled at
the 2013 CNS Annual Meeting, October 19-23
in San Francisco.
Internal Staff Operations – Our staff in
Schaumburg works diligently on your behalf.
We have made notable changes in our daily
operations to increase efficiency, devote more
staff resources towards understanding and
serving members, and create a more positive
work environment, which we anticipate will facilitate recruiting and retaining the best possible staff.
I look forward to serving you and this outstanding organization for many years to come.
The CNS will continue to grow and support you,
our members, through our effective volunteer
leaders, dedicated staff and most importantly,
listening and responding to your feedback. <
3
Joseph S. Cheng, MD, MS
Elderly Issues:
Our Society Getting Older
Our explosive growth in the utilization of neurological surgery can be linked to the associated
rise in our aging American population. According to the 2010 Census, our society is getting
older. While we typically associate the terms
“elderly” and “older” with those who have
retired, our aging population also affects
our “younger” work force. The percentage of
younger people in the United States between
the working ages of 25 to 44 years old has
declined by 3.4%, while the older population
within the working ages of 45 to 64 years old
has increased by 31.5%. The older working
group now makes up 81.5 million people in the
United States (US) population, and is associated
with the rising average age of our work force.1
In looking at those old enough to be in the
retirement age bracket in the US, age 62 years
and older, this group has increased by 21.2%.
Overall, those we expected to have retired from
the workforce, people 65 years and older, make
up 40.3 million people and represent 39% of
our total United States population. Between
2000 and 2010, this older age group represented the fast growth in the US and has been
associated with the rise in need of neurosurgical and spinal care, including adult degenerative spinal deformities (Table 1).
In addition to these statistics of the growing
number of “Baby Boomers” nearing retirement
age, the increase in our older US population is
also related to a trend for longer life expectancy
as noted with the fastest growing segment of our
US population being those 90 years and older.1
The number of people in the US who are 90
years and older has tripled over the past three
decades, reaching 1.9 million in 2010, and is
expected to quadruple over the next four decades
thanks to advances in medicine and healthcare.2
Due to our increasing life expectancy in the US,
those over the age of 90 years now represent
4.7% of the population over the age of 65, as
compared to being only 2.8% in 1980, and with
a projected increase to 10% of our older population in the US by the year 2050.1,2
As the number of our senior citizens increase, so will the need for age-appropriate
medical care. The majority of our older popula-
Table 1. Population Table of Age and Sex Composition Comparing 2000 to 2010 Data
From: Howden LM, Meyer JA. Age and Sex Composition: 2010 – 2010 Census Briefs. May 2011. http://www.census.gov/prod/cen2010/briefs/c2010br-03.pdf
4WWW.CNS.ORG
tion in the US has one or more disabilities, with
lumbar spondylosis and low back pain being the
most frequently reported musculoskeletal problems.2,3,4 Compared to other medical problems,
the disability associated with degenerative
spine disease is significant with a lower quality of life based on EQ-5D, which is a standardized measure of health status developed by the
EuroQol Group (Table 2). Based on a review
of the literature, it would appear that the disability associated with lumbar spondylosis is
more than twice that of prostate cancer, and is
more disabling than diseases such as congestive heart failure, chronic obstructive pulmonary
disease, or diabetes.
The disability associated with neurosurgical
and spine diseases becomes more significant
the older the patient becomes. For example,
those over 90 years old typically do not live
with their families, and either lives alone or in
a nursing facility. Their ability to live alone versus being institutionalized in a skilled nursing
facility becomes related to the management
of their disabilities affecting their independent
function.1 Given the prevalence of neurological and spinal disorders in the elderly population and their associated disability, it can be
expected that the need for medical care to promote a higher quality of life, or increase their
quality added life years (QUALY’s), including
surgery, is expected to exponentially increase
in an attempt to maintain the function and
overall quality of life in our older patients.
Many authors have identified a trend of rising medical care for the treatment of neurosurgical and degenerative spinal disorders in our
Medicare population, and assuming a stable
incidence of disease, concluded that there is
too much inappropriate medical and surgical
care being delivered. However, the population
Table 2. Overview of Baseline EQ-5D Indices, Number of Studies and Number of Patients for
Selected Disease States
data would indicate that we have a rapidly
growing older US population and that this is
associated with age-appropriate neurosurgical
and degenerative spinal disorders needing
medical and surgical care. Concern about our
growing health care costs has led to discussions on the cost-effectiveness of treatment
options. As neurological and spinal disorders
are associated with some of the highest rate of
disability and loss of independence for our
patients, understanding of the epidemiology in
our aging population is needed to avoid inappropriate rationing of care. The only way to
assess the appropriateness of our neurosurgical and spinal treatments is to analyze the
clinical variables and outcomes measurements for the effectiveness, versus looking at
absolute costs or rate of growth data alone, as
over-interpretation of any subset of data is
potentially misleading and dangerous. <
References
1
Howden LM, Meyer JA. Age and Sex Composition: 2010
– 2010 Census Briefs. May 2011. http://www.census.
Disease State
Number of
Studies
Number of
Patients
Mean EQ-5D
Index (SD)
Prostate Cancer
6
2,317
0.79 (0.23)
Diabetes Type II
32
35,348
0.76 (0.22)
IBD
5
1,229
0.75 (0.23)
COPD
11
7,495
0.70 (0.24)
ERSD/RF
8
2,126
0.66 (0.26)
Rheumatoid Arthritis
24
28,569
0.66 (0.22)
CHF
12
5,067
0.63 (0.25)
Statistics, National Center for Health Statistics (NCHS);
Knee OA
10
3,029
0.52 (0.26)
1985. Office-Based Ambulatory Care for Patients 75
PVD
9
1,824
0.50 (0.28)
Years Old and Over, National Ambulatory Medical Care
OA of the HIP
9
36,301
0.41 (0.31)
Lumbar Spondylosis
24
11,801
0.39 (0.26)
Total
137
135,106
WWW.CNS.ORG gov/prod/cen2010/briefs/c2010br-03.pdf
2
He W, Muenchrath MN. 90+ in the United States:
2006-2008-American Community Survey Reports.
November 2011. http://www.census.gov/
prod/2011pubs/acs-17.pdf
3
Bressler HB, Keyes WJ, Rochon PA, et al. The
prevalence of low back pain in the elderly: a systematic
review of the literature. Spine 1999; 24:1813–9.
4
Koch, H.; Smith, MC. DHHS publication (PHS).
Hyattsville, MD: Advance Data from Vital and Health
Survey, 1980 and 1981; p. 85-1250. 5
Matthew J. McGirt, MD
Saniya S. Godil, MD
Healthcare Cost, Quality and
the Aging Population: A Challenge to the
Neurosurgery Value Proposition
T
he current growth in healthcare cost is
unsustainable. Current healthcare costs
are nearly 18% of the U.S. GDP.1 Cost
of surgical care alone comprises 7% of U.S.
GDP.1 Without reform, healthcare costs are
expected to surpass half of U.S. GDP within the
next few decades. In an effort to shift financial
incentives from quantity of care to quality
of care, to increase transparency amongst
stakeholders, and empower the healthcare
consumer, the healthcare landscape is rapidly
shifting towards data-driven profiling and public
reporting of quality of care. With the emergence
of value-based purchasing, policy makers and
payers aim to shift care away from low value
treatments and low quality providers. This past
year, CMS released its nationwide claims data,
including physician identifiers, to the emerging
private market so that any “certified” entity may
provide physician and hospital performance
reports to the public. Because the demand for
such value-based purchasing has outpaced
the infrastructure to collect the requisite data,
the emerging environment of provider and
hospital quality reporting is currently reliant on
administrative claims data.
The Society of Thoracic Surgery (STS National Database), the American College of Surgeons (NSQIP), and recently, the AANS’ National
Neurosurgery Quality and Outcomes Database
(N2QOD), among others have emerged to offer
more relevant and accurate platforms to report
quality and value of surgical care. The Institute
of Medicine (IOM) and Agency for Healthcare
Research and Quality (AHRQ) define healthcare
Quality as, “the degree to which healthcare services for individuals and populations increase
the likelihood of desired health outcomes”.2
According to the IOM, Quality care is timely,
efficient, patient-centered, equitable, safe
and effective.2 In the healthcare value equation (Quality/Cost), safety and effectiveness
(Quality) of care is the numerator and healthcare cost the denominator. Central to patient
centered evidence-driven reform is quality and
value of care. As neurosurgeons enter a new
era with an unprecedented demand to demonstrate the quality of their care and the value
of the neurosurgical procedures they provide,
awareness of the factors that influence these
metrics is paramount.
As the demand to improve the value of care
is rapidly rising, so is the U.S. population of
adults over 65 years of age.3 Increasing age and
the elderly in particular, present a challenge to
the value proposition in neurosurgical care. In
almost all surgical disciplines, advanced age is
a major risk factor for adverse measures of patient-centered quality. Peri-operative morbidity,
mortality, re-operation, and hospital readmissions are all elevated in the elderly.4-6 Evidence
of health gains with surgery (effectiveness) in
the elderly is sparse in the neurosurgery literature. Because variance in surgical morbidity is
the largest driver of surgical cost7,8 and lack of
health benefit from surgery contributes to elevated cost from continued resource utilization,
today’s metrics suggest that the value of surgical care may be less for the elderly. Hence, an
increased proportion of elderly in a given healthcare population will have a multiplied effect on
the measured value of neurosurgical care; decreased quality with increased cost. Because
many degenerative neurosurgical pathologies
peak in the sixth decade of life, current valuebased paradigms may not be well suited to reward neurosurgical care of those who need it
most, the aging U.S. population.
Degenerative spine disorders represent the
majority of neurosurgical practice in the U.S.9,10
Using degenerative spine pathology as a case
study of cost, quality, and value, we present
the following institutional registry analysis. In a
single-institution, prospective, longitudinal outcomes spine registry at the Vanderbilt Spine
Center (VSC), all elective surgical care is prospectively measured and a representative sampling
of medical spine care is measured. Because this
non-research, quality improvement registry does
not require written consent, all care is measured
as is occurs. Hence, a true representation of
healthcare delivery is measured rather than a
confounded subset of the most motivated patients agreeing to partake in research.
In our experience, surgical spine care of the
elderly was associated with increased one-year
direct healthcare cost, increased peri-operative
morbidity, increased 90-day hospital re-admission, decreased effectiveness of care (quality of
life and disability improvement), and decreased
value (cost to obtain a full QALY-gain), Table 1.
When comparing providers or hospitals within
a market, or comparing treatments between
various disease states, increased proportions
of elderly will inevitably artificially deflate the
measured quality and value of care. This highlights the tremendous importance of appropriate risk-adjustment in quality reporting and
value analysis. Without valid risk-adjustment,
value-based strategies will mislead consumers, and analytics will report variance in patient
populations more than variance in quality of
care within healthcare delivery.
Despite the negative effect advanced age
had on quality and value of surgical spine care
at the VSC, the observed utility of lumbar spine
surgery in the elderly population (0.22 one-year
6WWW.CNS.ORG
Table 1. Measure of cost, quality, and value (benefit per cost) of care for lumbar fusion for
degenerative lumbar pathology as a function of patient age.
Quality
Age
Safety
90d Re-admit
Cost
Value ***
Effectiveness **
All Morbidity* 1yr ODI Improvement
Cost per QALY
70+
10%
19%
18%
$53,000
$176,000
30-60
7%
14%
24%
$44,000
$100,000
* All major and minor 90-day morbidity
** ODI: Oswestry Disability Index
*** Cost per QALY-gain as a two-year estimate
Figure 1. Mean quality adjusted life year (QALY) gains reported in literature after common
surgical interventions. The health state gain observed with lumbar surgery in the elderly was
superior to all surgical care except knee and hip replacement.
favorably even in the elderly, there is a growing
need to generate evidence to prove this to outside stakeholders, and to study the effect
increased age has on quality and value metrics.
Current quality and value-based paradigms
may not be well suited to reward neurosurgical
care of those who need it most, the aging U.S.
population. We as a specialty society and individual physician advocates for our patients
must engage in the emerging quality paradigm,
to help advance its methods for a patientcentered sustainable healthcare system. <
References
1
National Health Expenditure Projections 2011-2021.
Centers of Medicare and Medicaid Services. 2009;
http://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/National
HealthExpendData/Downloads/Proj2011PDF.pdf.
2
Lohr KN, Schroeder SA. A strategy for quality assurance in
Medicare. N Engl J Med. Mar 8 1990;322(10):707-712.
3
Wellness FIFoA-RSOAUKIo. http://www.agingstats.gov/
Main_Site/Data/2008_Documents/Population.pdf.
4
Kanter AS, Asthagiri AR, Shaffrey CI. Aging spine:
challenges and emerging techniques. Clin Neurosurg.
2007;54:10-18.
5
Kilincer C, Steinmetz MP, Sohn MJ, Benzel EC, Bingaman
W. Effects of age on the perioperative characteristics
and short-term outcome of posterior lumbar fusion
surgery. J Neurosurg Spine. Jul 2005;3(1):34-39.
6
Palmer RM. Perioperative care of the elderly patient:
an update. Cleveland Clinic journal of medicine. Nov
2009;76 Suppl 4:S16-21.
QALY-gain) compares very favorably to other
surgical treatments reported in the literature,
Figure 1. Comparing baseline and one-year
post-operative outcomes in the elderly within
the VSC registry, lumbar surgery resulted in
significant gains in back pain (VAS: 6.3 vs 3.2;
p<0.001), leg pain (VAS: 6.1 vs 2.4; p<0.001),
disability (ODI: 47.3 vs 28.0; p<0.001), physical quality of life (SF-12 PCS: 28.3 vs 38.9;
p<0.001), and one-year QALY-gained (0.57
vs 0.78; p<0.001). In a comprehensive literature review of all studies reporting the EQ-5D
QALY-gain after surgery, the health state gain
observed with lumbar surgery in the elderly was
superior to all surgical care except knee and
WWW.CNS.ORG hip replacement, Figure 1. Based on the literature to date and despite the challenges neurosurgeons face treating the elderly population,
the value of spine surgery remains very high
from a population health perspective, even in
its highest risk population; the elderly, Figure 1.
In an emerging healthcare reform landscape with increasingly fixed resources, attention is turning towards the relative quality and
value of care between disease states, treatments, and providers. The aging U.S. population presents a challenge to neurosurgical
providers and therapies treating this population sub-group. While many neurosurgical therapies are highly effective and compare
7
R.A. Rosenthal MEZ, M.R. Katlic. Common Perioperative
Complications in Older Patients. Principles and Practice
of Geriatric Surgery: Springer; 2011.
8
Vonlanthen R, Slankamenac K, Breitenstein S, et al.
The impact of complications on costs of major surgical
procedures: a cost analysis of 1200 patients. Annals of
surgery. Dec 2011;254(6):907-913.
9
Patil PG, Turner DA, Pietrobon R. National trends
in surgical procedures for degenerative cervical
spine disease: 1990-2000. Neurosurgery. Oct
2005;57(4):753-758; discussion 753-758.
10. Manek NJ, MacGregor AJ. Epidemiology of
back disorders: prevalence, risk factors, and
prognosis. Current opinion in rheumatology. Mar
2005;17(2):134-140.
7
Matthew J. McGirt, MD
Saniya S. Godil, MD
Prolonged Medical Management of Lumbar Spine
Disorders in the Elderly: Questioning its
Value, an Argument for Surgery
S
urgical treatments of structural low
back diseases are facing increasing
scrutiny on whether their cost justifies
the benefit to patients from a population health
perspective. This is particularly true in the
management of the elderly, where perceived
risk is higher and clinical utility less known.1,2
In the current paradigm, many elderly patients
with structural, and potentially surgically
correctable spine pathologies are subjected to
prolonged medical therapies given their age.
However, evidence to support this practice is
lacking. Whether prolonged medical treatments
of structural lumbar pathologies provides
effective improvement remains poorly studied
in elderly patients, particularly after failing an
initial medical trial when facing the option of
surgery. In a single-institutional spine centerwide prospective longitudinal outcomes registry,
we analyzed the two year outcomes of patients
>65 years old whom had surgically relevant
lumbar pathology (disc herniation, stenosis,
spondylolisthesis) that decided to undergo
prolonged medical management rather than
surgery. All patients had failed an initial 6-8
weeks of physical therapy, epidural injections,
and a multitude of non-narcotic and narcotic oral
medications.
A lack of improvement in back pain (VAS-BP),
leg pain (VAS-LP), low-back disability (ODI), physical QOL (SF12-PCS), mental QOL (SF12-MCS),
and depression (ZUNG) was observed after
comprehensive medical management (physical
therapy, epidural injections, anti-inflammatory,
muscle relaxant, and opioid medications), Table
1. Two-year costs average $8,236. Despite
costs nearing ten thousand dollars per patient,
there was no appreciable health benefit, suggesting that medical management of surgically
relevant pathology may be of minimal value
when prolonged after failing an initial six weeks
medical trial.
In a healthcare reform era embracing valuebased purchasing and patient-centeredness,
the Institute of Medicine (IOM), the Agency
for Health research and Quality (AHRQ), and
the Patient Protection and Affordable Care Act
(PPACA) have called for evidence from every
day practice to guide policy and purchasing
decision via registries. At the heart of this evidence driven reform process is safety and effectiveness (Quality) and cost of care, driving the
value equation (Quality/Cost). Critical to assessing the value of lumbar surgery in the elderly
or any patient population is a meaningful and
accurate comparison to a gold standard treatment option. To date, medical management of
surgically relevant pathologies such as lumbar
disc herniation, stenosis, and spondylolisthesis
has been assumed to be the gold standard for
which higher cost therapies should compare to.
However, evidence unequivocally supporting
multimodality medical therapy as an effective
and valuable treatment option for these structural and surgically relevant spine pathologies
remains debated. High quality evidence is particularly lacking in the elderly. The authors here
challenge the notion that long-term medical
therapy for three common surgical low-back pathologies are effective and valuable treatment
options at the time point when surgery in considered; that is when lack of medical response
has already been demonstrated.
Generating accurate and meaningful
evidence from medically managed cohorts that
allows for an “apples to apples” comparison
to surgery patients has historically been a
challenge. To make a meaningful comparison
for value analysis, one must minimize
confounding that is inherent to the shared
decision to undergo surgery (selection bias),
limiting the use of non-randomized prospective
cohort studies. However, ethical constraints of
randomized controlled trials (RCTs) mandating
the allowance of treatment group cross-over
also results in confounded medical treatment
cohorts. In non-randomized studies, medically
Table 1. Baseline characteristics and patient reported outcomes of fifty patients undergoing comprehensive medical management for degenerative lumbar spondylolisthesis, stenosis or disc herniation.
Patient Demographics
Variables
N=50
Age
69.4 ± 4.8
26 (52.0%)
Male
Diagnosis
Patient Reported Outcomes
Baseline
2-years
P value
NRS-BP
7.2 ± 2.8
6.1 ± 3.3
0.08
NRS-LP
7.5 ± 2.5
6.5 ± 3.3
0.10
ODI (%)
58.7 ± 18.1
52.0 ± 20.5
0.09
Disc Herniation
15 (30.0%)
SF-12 PCS
30.2 ± 7.5
30.7 ± 9.0
0.76
Stenosis
21 (42.0%)
SF-12 MCS
49.0 ± 12.9
50.2 ± 12.7
0.65
Spondylolisthesis
14 (28.0%)
Zung
Depression
34.9 ± 11.8
33.5 ± 11.6
0.55
8WWW.CNS.ORG
managed patients tend to represent those
patients most satisfied with or responsive to
medical treatment, whereas surgical cohorts
represent those patients not responsive and
least satisfied with their initial trial at medical
therapy. In RCTs such as SPORT, an intentto-treat analysis generates a medical cohort
confounded by inclusion of surgically treated
patients,3 and the “as treated” analysis by
definition generates a medical cohort of
patients that remain only after non-responders
to medical treatment have crossed over to
surgery, artificially elevating the group mean
measure of effectiveness.4 Neither study design
can answer the question: Is prolonged medical
treatment effective? Hence, comparison
studies to date provide a cloudy assessment of
the effectiveness and value of medical therapy;
evidence specific to the elderly even more so.
The authors feel that prospective longitudinal registries offer unique advantages to
assessing single treatment cohorts in everyday
care. In accordance with the IOM, AHRQ, and
the PPACA, careful case definitions within a
prospective registry can allow for a measured
and homogenous patient population that is
most similar to those patients whom surgery is
offered to, without artificially effecting measurement do to research study constraints.
Our findings demonstrate lack of improvement in every validated, patient-centered outcomes instrument employed. Even if powered
appropriately so that the observed, non-significant, small health gains did reach statistical
significance, none of them would have reached
clinical significance (MCID). The cost of medical therapy observed in our practice was almost
entirely direct medical cost, as occupational
losses of patients and caregivers (indirect cost)
were minimal. While the observed costs here
were only a third of costs previously reported for
surgical cohorts,5-8 our results suggest that there
was no sustained benefit to justify these costs,
questioning the value of continued medical
treatment in patients failing to show improvement in the first 6-8 weeks of therapy. There are
a few reasons why our findings challenge previous reports. Medical management outcomes
WWW.CNS.ORG studies that include patients 1) without well
defined surgically relevant structural pathology,
2) that have not fully engaged in an initial trial
of the medical therapy to be studied, 3) that
demonstrate even modest improvements with
their initial trial of medical management, or 4)
exclude patients that subsequently choose to
undergo surgery do to their poor outcomes with
medical treatment will inevitably demonstrate
greater effectiveness of medical treatment in
those measured populations. However, based
on current evidence-based guidelines, those
patient populations are not who surgery should
be offered to in the first place.9
It is important to highlight the fact that comprehensive medical management is very effective in managing the “sea” of low back and leg
pain patients, and should be considered as first
option. This is particularly true in the elderly,
where increased age is associated with greater
morbidity and cost.1,2,10 The vast majority of lumbar pathologies and symptoms will respond to
medical therapies. It is only in the small subset
of patients with documented structural spine
pathology, with symptoms corresponding to
those structural pathologies, and that demonstrate no improvement after fully engaging in
multi-modality medical treatment that continued medical treatment may be of least value. It
is this subset of elderly patients where surgery,
despite its cost and risks, is likely the most valuable treatment option, from both a value-based
and patient-centered perspective. Loosing sight
and grasp of an appropriate “apples to apples”
medical comparison group most relevant to
surgical subsets of the elderly population will
create an artificial headwind against the true
value of surgical treatment options for the growing
elderly population in America.
From a short-term cost-based purchasing
and risk perspective, prolonged medical
management appears favorable in the elderly
population. From a value-based purchasing and
patient-centered effectiveness perspective,
prolonged medical management may be an
inferior treatment option in the elderly
population with surgical degenerative lumbar
disorders. Patient age alone should not drive
caregivers away from considering surgical
management of lumbar spine disorders. <
References
1
Kanter AS, Asthagiri AR, Shaffrey CI. Aging spine:
challenges and emerging techniques. Clin Neurosurg.
2007;54:10-18.
2
Kilincer C, Steinmetz MP, Sohn MJ, Benzel EC,
Bingaman W. Effects of age on the perioperative
characteristics and short-term outcome of posterior
lumbar fusion surgery. J Neurosurg Spine. Jul
2005;3(1):34-39.
3
Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical
vs nonoperative treatment for lumbar disk
herniation: the Spine Patient Outcomes Research
Trial (SPORT) observational cohort. JAMA. Nov 22
2006;296(20):2451-2459.
4
Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs
nonoperative treatment for lumbar disk herniation:
the Spine Patient Outcomes Research Trial (SPORT):
a randomized trial. JAMA. Nov 22
2006;296(20):2441-2450.
5
Adogwa O, Parker SL, Shau DN, et al. Cost per
quality-adjusted life year gained of revision neural
decompression and instrumented fusion for same-level
recurrent lumbar stenosis: defining the value of surgical
intervention. J Neurosurg Spine. Feb 2012;16(2):
135-140.
6
Adogwa O, Parker SL, Shau DN, et al. Cost per qualityadjusted life year gained of laminectomy and extension
of instrumented fusion for adjacent-segment disease:
defining the value of surgical intervention. J Neurosurg
Spine. Feb 2012;16(2):141-146.
7
Adogwa O, Parker SL, Davis BJ, et al. Cost-effectiveness
of transforaminal lumbar interbody fusion for Grade I
degenerative spondylolisthesis. J Neurosurg Spine. Aug
2011;15(2):138-143.
8
Glassman SD, Polly DW, Dimar JR, Carreon LY.
The cost effectiveness of single-level instrumented
posterolateral lumbar fusion at 5 years after surgery.
Spine (Phila Pa 1976). Apr 20 2012;37(9):769-774.
9
NASS. Evidence-Based Clinical Guidelines for
Multidisciplinary Spine Care. 2007; http://www.spine.
org/Documents/NASSCG_stenosis.pdf.
10 Raffo CS, Lauerman WC. Predicting morbidity and
mortality of lumbar spine arthrodesis in patients
in their ninth decade. Spine (Phila Pa 1976). Jan 1
2006;31(1):99-103.
9
James S. Harrop, MD, FACS
Spine Surgery in an Increasingly
Aging Population
A
s physicians, as well as members of
society as a whole, it is apparent that
our population is increasingly aging.
Whether we are seeing patients in clinic or
reading an article in the newspaper, there are
constant reminders that the “baby boomers”
are getting older. However, not only is the
population demographic shifting; there are
also aspects of the baby boomer generation
which create unique spine care requirements.
For example, this group of individuals is very
committed and focused on their quality of
life and independence. As a generation, they
maintain their physical attributes extremely well
by keeping active and are unwilling to become
labeled as “elderly.” Unfortunately, this intense
physical activity puts unique stresses on their
spines, and concurrently, as one ages, the
spine has a higher incidence of osteoporosis,
other metabolic bone loss, and degeneration.
Fortunately, with this increase in prevalence of age-related spinal deformities and
degenerative scoliosis, there has been a concurrent improvement of our knowledge of spinal sagittal alignment and pelvic parameters
(See Michael Wang’s article on page 11). Operations for these deformities are associated
with a high morbidity and are particularly difficult on elderly individuals. The potential benefits for surgical treatment are very high but
must be weighed against the cost of these
operations. Use of long constructs with numerous spinal implants is quite expensive. These
costs need to be calculated not only by the
individual, but for society in general. This enacts a difficult debate on cost versus function,
particularly in an elderly population and what
society’s overall goals are.
> It is interesting that over the last 25 years,
there has been a 600% increase in the mean
age of individuals that received care. <
Although the aging population impacts
numerous aspects of spine care, this article
reviews its effect on spinal cord injury (SCI).
The SCI population has significantly changed
over the last 10 to 25 years. At Thomas Jefferson University Hospital and Delaware Valley
SCI Center, approximately 200 SCI individuals
are cared for each year. It is interesting that
over the last 25 years, there has been a 600%
increase in the mean age of individuals that
received care. In the 1970s, the mean patient
age was 28.7 years, increasing to 31 years,
35 years, and 39 years in the 1980s, 1990s,
and 2000s, respectively. Recently, from 2010
to 2012, the mean patient age was 42.6 years.
While the overall means do not seem to be
high, we must remember that SCI occurs in a
bimodal distribution; one group being younger
patients and the other being elderly patients.
Younger patients are typically affected by highenergy traumatic injuries, and SCI in elderly patients is due to lower energy injuries, such as
falls from height.
This bimodal observation is supported
when analyzing the statistics of types of injuries. Paraplegic SCI occurs from a very high
mechanism of injury which fractures the thoracic spine and ribcage. Thus, aging would not
be expected to change the incidence. This is
supported by the data where the paraplegic
population has minimally changed with complete paraplegics dropping from 27.7% to 18%
and incomplete paraplegics slightly increasing
from 17.6% to 18.3%. The occurrence of tetraplegic (complete loss of all motor and sensation) SCI has significantly declined from 25%
in the 1970s, to presently only accounting for
11.6% of SCI.
However, incomplete tetraplegic SCI patients have increased from 28.1% to over
40%, presently. So, why is this happening?
Unfortunately, as patients age, their spines
tend to stiffen due to degenerative changes,
and the result is that the spine becomes
more ankylosed, in addition to loss of disc
height. Elderly patients also tend to concurrently develop neurologic decline due to
length dependent neuropathies, as well as
the possibility of unknown cervical myelopathies. The result is loss of coordination and
difficulty with gait. The synergistic loss of visual clues predisposes these patients to
higher risks of falls and lower mechanism injuries. Thus, stiff spine and repetitive lower
energy falls makes these patients extremely
susceptible to cervical spine injuries and particularly central cord SCI and/or incomplete
tetraplegic injuries. Therefore, as we move
forward, it is important to not only concentrate on treatment of SCI, but also preventive
mechanisms. Examples include screening our
elderly patients in terms of home safety, as
well as assessments for neuropathies, visual
loss, and myelopathies. <
10WWW.CNS.ORG
Michael Y. Wang, MD,
FACS
SPINAL DEFORMITIES IN AN AGING
POPULATION
Epidemiological Context
Advances in health care, safety, nutrition, and
sanitation have resulted in an unprecedented
prolongation of the lifespan for citizens of the
“developed world.” The current life expectancy
for a U.S. citizen who has survived to the age
of 65 is now 82; 84.89 years for men and 94
years for women. In fact, it is now predicted
that by the year 2050, there will be over 4.2
million Centenarians in the U.S. (Figure 1).1
This is despite a relatively stable national population size overall.
The aging of the American population poses
specific challenges for the spinal neurosurgeon.
Degeneration of the vertebral column continues
to progress with age, and disc disease, facet
joint arthropathy, and spinal stenosis are wellknown entities that may require surgical treatment. The surgical and anesthetic management
of these increasingly older individuals poses
challenges to the neurosurgeon.
Figure 1. Number of U.S. centenarians
WWW.CNS.ORG Surgical Management of the
Elderly Spine
Spinal neurosurgery in the elderly is intrinsically
complex.2 A myriad of disease entities as well as
diverse treatment options render decision-making for the surgeon and patient ever more complex. In particular, the following issues can be
more involved in the elderly spinal population:
• Anesthetic management–The risk of anesthetic complications increases with age.
Compromised cardiopulmonary function, as
well as increasing medical co-morbidities necessitates limiting the amount of time elderly
patients remain under general anesthesia.
In addition, there is an increasing recognition
that memory and cognitive processes are
susceptible to prolonged general anesthesia.
• Multi-level disease–In the past, it was often
felt that patients with a radiculopathy or
neurogenic claudication typically harbored
primarily single-level disease. However, with
increasing age, the degree of degenerative change increases frequently at several
levels. This poses not only the problem of
accurately diagnosing the offending spinal
level, but also introduces the very distinct
possibility that several spinal levels may
be responsible for the patient’s presenting
symptoms, even in cases of primarily neurological symptoms. An increasing reliance on
anesthetic test injections has resulted from
the complex process of discerning which of
several abnormal levels may be causing a
patient’s symptoms. In addition, a reasonable alternative strategy is to treat the patient at multiple levels.
• Imaging considerations–A proliferation of
implantable electronic devices (cardiac defibrillators and pacers, nerve stimulators,
etc.) has made it impossible for an increasing population of patients to receive magnetic resonance imaging. CT myelography
testing reveals different anatomic features
and is the best alternative to magnetic resonance, but poses some risks due to its invasive nature and administration of contrast
agents. A younger generation of spinal surgeons has now begun to re-learn the art of
interpreting myelographic imaging.
• Osteoporotic bone–Internal fixation has
revolutionized spinal surgery. In the setting of osteoporosis, surgeons are forced
to manage the patient with weaker skeletal
anchor points using cement augmentation,
longer fusion constructs, alternative screw
designs, or avoiding instrumentation altogether. However, even for patients undergoing decompression alone, a greater respect
for the limited integrity of the spinal column
is needed in the setting of osteoporosis.
In either case it behooves the surgeon to
11
A
B
C
D
Figure 2. A & B) AP and C & D) lateral 36-inch films showing correction of a severe kyphoscoliotic spinal deformity in an 79-year-old female.
become knowledgeable about the rapid
advances in medical management of osteoporosis.
• CSF leakage–As patients age, the Dura
mater becomes progressively thinned. This
is coupled with an increasing use of epidural
steroid injections. The end result is a greater
risk of spinal fluid leakage in general. For
the elderly, the consequences of Dural
breaches are more significant, as prolonged
bed rest increases perioperative morbidity.
This patient population is also at greater risk
for intracranial subdural collections from
iatrogenic or therapeutic reductions in CSF
pressure.
• Post-operative care–The elderly population
also poses increased risks of complications
in the post-operative period. Older patients
are more susceptible to “sundowning” and
slower to mobilize in general, and hyponatremia is a common finding. Concomitant arthritides in the hip and knee joints can also
impair postoperative mobilization.
Spinal Deformity & Aging
Scoliosis and kyphosis are increasing in prevalence with the aging population. Data from the
National Health and Nutrition Examination Survey (NHANES) study estimates the prevalence
rate of scoliosis at 8.3% in adults (defined
as greater than 10° curves).3 Furthermore,
as patients age, they are at risk for progressive deformity progression. With more severe
curves, the surgical enterprise must often be
expanded to include more spinal fusion levels,
more osteotomies, or combined approaches
from the anterior or lateral approach. Independent of the magnitude of the surgery,
more severe deformities also carry a higher
risk of complications. With adult deformities,
it is necessary to first destabilize the spine, actively correct the deformity, and then stabilize
it through internal fixation and fusion. Thus,
larger deformity corrections require more destabilization, a greater degree of neural manipulation during curve correction, and stronger
fixation (Figure 2).
Complications in Spinal
Deformity Surgery
Surgical complications are common with adult
spinal deformity surgery. Charosky reviewed
prospective data from six French spine centers. Their study population included 306 patients older than 50 years of age with a mean
curve of 50°. 10% of patients had anterior
surgery only, 18% had double anteroposte-
12WWW.CNS.ORG
rior approach, and 72% had posterior surgery
only. There were no cases of death or blindness. However, common complications that
occurred were infection (5.2%), neurological
complications (7%), reoperations (26%), and
mechanical complications (24%). This resulted
in an overall complication rate of 39%.4
Acosta, et al. reviewed data on a somewhat
older population, including only those over the
age of 75, undergoing deformity surgery of at
least six spinal levels. Of their 21 patients,
the mean patient age was 77, and 71% had
at least one major medical co-morbidity. 62%
had at least one peri-operative complication
and 38% had at least one major complication.
Revision surgery was necessary in 14% of patients, and long-term complications occurred
in 52%. There were no peri-operative deaths.
Increasing age was predictive of any perioperative complication (p = 0.03), but major
complications were not predicted by age or comorbidities.5
Furthermore, even patients recovering well
from the surgery are at risk for delayed complications. Under-correction of deformities,
proximal junctional kypjosis, pseudarthrosis,
and hardware failure are potential late complications of these extensive surgeries. For
example, Smith, et al. found in a study of 442
patients that 6.8% of spinal deformity patients
suffered a rod fracture, and 15.8% of PSO patients had a fracture.6 The majority of these
patients required a subsequent revision operation. Some surgeons attempt to limit the number of levels treated as a strategy to reduce
the magnitude of the surgical enterprise. This
strategy reduces anesthetic time, blood loss,
recovery periods, and the likelihood of pseudarthrosis. However, it is also critical to correct
the patient’s deformity to a degree that will result in adequate long term outcomes. Kasliwal,
et al. demonstrated this with their finding that
40% of their studied deformity patients had
previously undergone a short segment surgical
fusion which later needed to be revised due to
inadequate deformity treatment.7
WWW.CNS.ORG The Importance of Sagittal
Balance
There is an increasing recognition that proper
maintenance and/or restoration of sagittal balance is critical to the success of adult spinal
deformity surgeries. This often requires more
complex operations designed to destabilize
and re-align the spine. Lafage, et al. studied
a population of patients undergoing 3-column
osteotomy to fix rigid adult deformities, investigating the measures of lumbar lordosis,
sagittal vertical axis, and pelvic tilt on clinical outcomes. In their study of 41 patients, a
greater degree of pelvic tilt and longer sagittal
vertical axis predicted poor spinal-pelvic alignment, and this correlated with poor clinical
outcomes.8
Thus, for surgeons planning adult deformity
operations, particular attention should be paid
to obtaining adequate sagittal alignment by
matching the degree of desired lumbar lordosis to the pelvic incidence. Failure to achieve
the optimal result is typically the result of planning an operation which does not provide the
needed degree of correction in the sagittal
plane. This is more likely in the elderly population given concerns over the magnitude of the
surgical enterprise in patients who are more
susceptible to the consequences of prolonged
anesthesia, significant blood loss, and immobilization. Staging the operation over two or
three sessions is one option for managing this
risk in the elderly.
of these surgeries as determined by quality
adjusted life years (QALY) is reasonable, given
the severely limiting nature of these pathologies compared to other orthopedic surgical
procedures.9 <
REFERENCES
1
199RV: US Department of Health & Human Services,
US Department of Commerce, US Census Bureau;
1990:1-24.
2
Wang M, Sherman A, Vanni S, Levi A, life BGLssitfqo.
Lumbar stenosis surgery in the fourth quartile of life.
Neurosurg Focus. 2003;14(2):1-4.
3
Carter O, Haynes S. Prevalence Rates for Scoliosis
in US Adults: Results from the First National Health
and Nutrition Examination Survey. Int J Epidemiol.
1987;16(4):537-544.
4
Charosky S, Guigui P, Blamoutier A, Roussouly P,
Chopin D. Complications and risk factors of primary
adult scoliosis surgery: a multicenter study of 306
patients. Spine. 2012;37(8):693-700.
5
Acosta F, McClendon J, O’Shaughnessy B, et al.
Morbidity and mortality after spinal deformity surgery
in patients 75 years and older: complications and
predictive factors. J Neurosurg: Spine. 2011;15(6):667674.
6
Smith J, Shaffrey C, Ames C, et al. Assessment of
symptomatic rod fracture after posterior instrumented
fusion for adult spinal deformity. Neurosurg.
2012;71(4):862-867.
7
Kasliwal M, Smith J, Shaffrey C, et al. Does prior
short-segment surgery for adult scoliosis impact
perioperative complication rates and clinical outcome
Healthcare Economics
The increasingly aging population with its
greater prevalence of spinal deformities will
have to be managed in a coming era of economic restrictions. Spinal deformity surgeries
carry significant costs. Prolonged surgeries
with a heavy reliance on adjuncts for bony fusion, numerous spinal implants, long hospitalizations, high rates of complications, and the
need for inpatient rehabilitation all add to the
costs for caring for this patient population.
However, evidence is emerging that the value
Krach C. Centenarians in the United States. Vol P23-
among patients undergoing scoliosis correction? J
Neurosurg: Spine. 2012;17(2):128-133.
8
Lafage V, Smith J, Bess S, et al. Sagittal spino-pelvic
alignment failures following three column thoracic
osteotomy for adult spinal deformity. Eur Spine J.
2012;21(4):698-704.
9
Lafage V. Likelihood of Reaching Minimal Clinically
Important Difference (MCID) in Health Related Quality
of Life (HRQOL) Measures: Prospective Analysis of
Operative and Non–operative Treatment of Adult
Spinal Deformity (ASD). AANS/CNS Joint Spine Section
Meeting. Phoenix, Arizona 2013.
13
Nicholas Ferraro, MD
Ryan Kitagawa, MD
M. Ross Bullock, MD, PhD
Traumatic Brain Injury in the Elderly
The Problem
W
hether you work in a major academic
center or a community hospital, the
midnight emergency room telephone
call for an elderly patient with a chronic
subdural hematoma is almost routine in every
neurosurgical practice. With over 10 million
traumatic brain injuries (TBI) worldwide per
year, over 1.5 million TBI cases per year in the
United States, and an aging population, the
problem promises to increase.1
Based on anecdotal and published data,
most of us would agree that older patients
generally have worse outcomes after TBI.
Specifically, older patients are more likely to
have multiple medical co-morbidities, to take
anti-coagulation or anti-platelet medication,
and to have more severe injuries compared
to their younger counterparts. Many neurosurgeons would have serious reservations about
taking warfarin or Plavix themselves, and we
speculate that few would consent to having a craniotomy for a subdural hematoma
after the age of 80. However, it is important
to make decisions for our patients based on
objective data.
Outcomes
In TBI, age has long been recognized as a
predictor of poor outcome. Older TBI patients
have two times higher mortality, more complications, longer hospitalizations, and six times
higher unfavorable outcomes when compared
to younger individuals. Elderly patients are
also more likely to die in the months that follow
their intensive care unit stay when compared
to younger patients and are more likely to have
poor functional outcomes.2-4 Obviously, these
general findings should make us all think very
carefully about taking an elderly patient for
surgery, but what age should be considered
“elderly”?
The general trauma community teaches
that anyone older than 40 years old has a
worse outcome, but a recent study showed
that overall mortality increases for patients
greater than 56 years old independent of
injury severity. For TBI specifically, the mortality steadily increased with age to a peak at
75 years old.5 However, other authors have
shown that although the risk of death from
TBI is higher for patients over the age of 65,
the proportion of severe TBI is higher as well
and therefore, age may not be the only factor
causing a higher mortality. Additionally, one
study showed that patients who survive to 6
months after injury will be expected to live a
normal life span for their age.6 Like everything
else in our specialty, it’s all about the individual patient and a careful assessment of risk.
While “70 is the new 50,” an individual of
any age may be extremely fit or have severe
co-morbidities such as alcoholism or coronary
artery disease.
Special Considerations
One of the most commonly encountered conditions in the elderly is the chronic subdural
hematoma (SDH). Above the age of 65, the
incidence is 8 to 58 per 100,000 individuals, and the recurrence rate after evacuation
ranges from 2% to 28%.7 Every neurosurgeon
carries memories of disastrous SDH patients,
and yet our treatment approaches are highly
varied and include craniostomy with subdural
drain or vacuum drainage, burr hole(s), craniotomies, and craniectomies. However, the only
surgical maneuver that is supported by Level
I data is the use of subdural drains after burr
holes.8
Based on our own literature review, we
favor burr holes as the primary procedure
for chronic SDH. We attempt two burr holes,
leave a subdural drain, and keep the head
of bed flat for 24 hours. We initiate thromboprophylaxis with subcutaneous heparin
at 36 to 48 hours after surgery depending
on the postoperative imaging and generally
repeat burr holes once for recurrence prior
to proceeding with craniotomy.9 On the other
hand, in cases of severe medical co-morbidities or the presence of dense membranes
we favor bedside craniostomy or mini-craniotomy, respectively.
Anticoagulants and antiplatelet agents are
also frequently used in the elderly for coronary artery disease, cerebrovascular ischemia, and thromboembolic conditions and
are worth special consideration. Antiplatelet
agents such as aspirin and Plavix are almost
ubiquitous in this patient population, but it
has been demonstrated that in TBI, patients
taking Plavix have a higher mortality and are
more likely to be discharged to long-term inpatient facilities after their initial hospitalization.10 Currently, the only treatments for these
agents are platelet transfusions and desmopressin. Interestingly, some TBI studies have
shown that no statistically significant difference exists between the antiplatelet treated
patient groups who did and did not receive a
platelet transfusion despite similar Glasgow
Coma Scale scores and Injury Severity Scale
scores.11 However, in the absence of better
therapy, platelet transfusion seems to be the
most logical option for these difficult and increasingly more common patients.
14WWW.CNS.ORG
Similar to aspirin and Plavix, TBI patients
who take warfarin demonstrate worse outcomes. More specifically, longer Intensive Care
Unit (ICU) stays and hospitalizations have been
found.10 Unlike using platelet transfusions to
reverse aspirin and Plavix use, studies have
shown that the rapid correction of warfarin induced coagulopathy does improve outcome in
patients with intracerebral hemorrhage.12 Recombinant factor VII is also available for urgent
reversal of warfarin induced anticoagulation
when there is insufficient time to use fresh frozen plasma (FFP) or vitamin K. In our practice,
we use Recombinant factor VII when patients
need emergent cranial surgery or when the risk
of deterioration is very high. Whenever factor VII
is used, FFP should also be given and coagulation studies should be followed for 48 hours
due to the risk of “rebound anticoagulation.”
Further complicating this issue is the fact that
new anticoagulants, which do not have safe or
effective means of reversal, are being released
into the market. These new medications include
dabigatran and rivaroxaban.
Mild TBI in the elderly is worth mentioning.
Mild TBI accounts for up to 80% of TBI in the
United States. Although only 1% of mild TBI
patients required an operative intervention,
64% of these interventions were performed
on patients greater than 65 with a mortality rate of 28%.13 Thus, elderly patients may
warrant admission to the hospital more frequently to monitor for neurologic worsening
or to prevent medical complications such as
pneumonia or deep vein thrombosis.
Moderate and severe TBI are also more
significant in the elderly. Mortality rates over
50% have been reported in elderly patients
with moderate and severe TBI, and the only
WWW.CNS.ORG surgical option for elevated intracranial pressure, decompressive craniectomy (DC) is associated with a worse outcome. In one study
of elderly patients who had a DC, the ICU mortality was 48%, the in-hospital mortality was
57%, and poor outcomes occurred in 82% of
patients at hospital discharge.14
Conclusion
TBI in the elderly is a worldwide problem that
will continue to increase in frequency. Their
medical problems are more complex, their relative injuries are worse, and their physiologic
reserve is less. Little data exists to help us in
treating these patients, and therefore sound
judgment and experience are the best guides.
Clearly more research studies are needed to
answer some of these questions. <
References
1
2
Schouten JW, Mass AIR. Epidemiology of traumatic brain
brain injury: a population-based study of the role of age
and injury severity. J Neurotrauma 2007;24:435-445.
7
Ducruet AF, Grobelny BT, Zacharia BE, Hickman
ZL, DeRosa PL, Anderson K, et al. The surgical
management of chronic subdural hematoma.
Neurosurg Rev 2012;35:155-169.
8
Santarius T, Kirkpatrick PJ, Ganesan D, Chia HL, Jalloh
I, Smielwski P et al. Use of drain versus no drains after
burr-hole evacuation of chronic subdural haematoma:
a randomized controlled trial. Lancet 2009;374:10671073.
9
Weigel R, Schmiedek P, Krauss JK. Outcome of
contemporary surgery for chronic subdural haematoma:
evidence based review. J Neurol Neurosurg Psychiatry
2003;74:937-943.
10 Wong DK, Lurie F, Wong LL: The effects of clopidogrel
on elderly traumatic brain injured patients. J Trauma
2008;65:1303-1308.
11 Downey DM, Monson B, Butler KL, Fortuna G, Saxe
JM, Dolan JP, et al. Does platelet administration
affect mortality in elderly head-injured patients taking
Mosenthal AC, Lavery RF, Addis M, Kaul S, Ross S,
antiplatelet medications? The American Surgeon
2009;75:1100-1103.
12 Ivascu FA, Howells GA, Junn FS, Bair HA, Bendick PJ,
outcome. J Trauma 2002;52:907-911.
Janczyk RJ. Rapid warfarin reversal in anticoagulated
Stocchetti N, Paterno R, Citerio G, Beretta L, Colombo
patients with traumatic intracranial hemorrhage
A. Traumatic brain injury in an aging population. J
reduces hemorrhage progression and mortality. J
Neurotrauma 2012;29:1119-1125.
Susman M, DiRusso SM, Sullican T, Risucci D, Nealon
Trauma 2005;59:1131-1139.
13 Moore MM, Pasquale MD, Badellino M. Impact of
P, Cuff S, et al. Traumatic brain injury in the elderly:
age and anticoagulation: need for neurosurgical
increased mortality and worse functional outcome
intervention in trauma patients with mild traumatic
at discharge despite lower injury severity. J Trauma
2002;53:219-224.
5
PK, Brown AW. Relative risk of mortality after traumatic
Philadelphia: Elsevier Saunders; 2011; 3270-3277.
age is an independent predictor of mortality and early
4
Flaada JT, Leibson CL, Mandrekar JN, Diehl N, Perkins
injury. In: Winn HR, ed. Youmans Neurological Surgery.
Marburger R, et al. Isolated traumatic brain injury:
3
6
brain injury. J Trauma 2012;73:126-130.
14 De Bonis P, Pompucci A, Mangiola A, Paternoster G,
Kuhne CA, Ruchholtz S, Kaiser GM, Nast-Kolb D.
Festa R, Nucci CG, et al. Decompressive craniectomy
Mortality in severely injured elderly trauma patients
for elderly patients with traumatic brain injury:
– when does age become a risk factor? World J Surg
it’s probably not worth the while. J Neurotrauma
2005;29:1476-1482.
2011;28:2043-2048.
15
Robert M. Starke, MD, MSc
L. Fernando Gonzalez, MD
Pascal M. Jabbour, MD
Stavropoula I.
Tjoumakaris, MD
Management of Cerebral
Aneurysms in the Elderly
T
he elderly population has grown
significantly since 1950. This is in part
due to increased life expectancies
and improved overall healthcare. With the
expansion of this population, there will be an
increase in the number of patients with cerebral
aneurysms. The increase in non-invasive
imaging will also contribute to the diagnosis
of unruptured aneurysms in asymptomatic
elderly patients.1 Currently, the elderly and
females comprise the largest demographic
groups amongst patients with subarachnoid
hemorrhage (SAH). 2, 3 Older age and an
increased incidence of medical comorbidities
places these patients at increased risk of poor
outcome following treatment and increase the
chances for associated medical complications.
Unruptured Aneurysms
Currently, the management of patients with
unruptured aneurysms is controversial and
this area is even less clear in the elderly. At
some centers, both endovascular and microsurgery have been carried out on patients into
the ninth decade. In a number of countries,
patients with unruptured aneurysms and advanced age are not offered intervention, but
with the improvements in endovascular options, treatment has been offered to a greater
percent of elderly patients. The algorithm of
whether to treat or observe an unruptured aneurysm in an elderly patient requires a careful estimation of life expectancy, an honest
assessment of procedural risks, and a clear
estimation of the natural history.
Unfortunately, the natural history of unruptured intracranial aneurysms is not entirely
clear. The International Study of Unruptured
Intracranial Aneurysms4 and the Unruptured
Cerebral Aneurysm Study5 did not find age
to be a significant risk factor for rupture, but
younger age may be a risk factor for rupture
due to the potentially increased life-years at
risk. Size, location, symptomatic presentation,
and presence of a daughter sac have been
associated with the risk of rupture and these
factors must be carefully balanced against patient and procedural risks. All factors must be
carefully assessed in each patient to provide
the optimal management.
Ruptured Aneurysms
Trials concerning ruptured cerebral aneurysms
have found age to be a major predictor of outcome.6-10 Additionally, neurological condition
following rupture is a significant independent
risk prognostic factor in overall outcome.7, 11
The reported number of elderly patients achieving favorable outcomes following treatment
of aneurysmal SAH varies significantly due to
patient, aneurysm, and treatment related factors but has been reported to be between 5090% for overall cohorts, but 15-50% for treated
poor grade patients.12-20 Due to the high rates
of rebleeding and associated complications,
treatment is indicated in the majority of patients; however, an honest conversation must
be made with the patient’s family, and when
possible, the patient.
Endovascular versus
Microsurgical Clipping
The optimal treatment of cerebral aneurysms
in elderly patients remains unclear. These patients tend to have higher complications rates
related to surgical therapy, but endovascular
therapy is complicated by more difficult access, vessel tortuosity, and atheromatous alterations. In the International Subarachnoid
Aneurysm Trial (ISAT) lower rates of morbidity
and mortality were associated with endovascular coiling as compared to microsurgical clipping for the overall population.6, 7, 11 With longer
follow-up overall outcome in the microsurgical
Robert H. Rosenwasser, MD
Aaron S. Dumont, MD
cohort approached the endovascular cohort.
Episodes of rebleeding and retreatment were
higher in the endovascular cohort, and the incidence of seizures was higher in the microsurgical cohort. Rates of rebleeding in elderly
patients (0-3%) along with retreatment rates
(5-17%) have also been similar as compared
to the general population,13-16, 19 but direct
comparisons are difficult due to differences
in overall patient and aneurysm characteristics. For elderly patients with fewer potential
years of both rebleeding and retreatment and
increased risk of upfront complications following microsurgery, endovascular therapy may
be the optimal therapeutic modality even if
it is less durable. In a subgroup analysis of
the ISAT, for patients older than 70 years of
age there was no significant difference in outcome between the 83 of 138 patients (60.1%)
treated with endovascular coiling versus 78
of 140 (56.1%) in the microsurgical cohort.16
Patients with internal carotid and posterior
communicating artery aneurysms had better
outcomes when treated with endovascular
therapy (72%) versus microsurgery (52%),
but patients with middle cerebral artery aneurysms had better outcomes when treated with
microsurgery (86.7%) versus endovascular
(45.5%). With potential improvements in endovascular therapies, a number of studies have
found improved outcomes in elderly patients
treated with endovascular therapies. With the
increase in endovascular technology including
the use of balloon remodeling, stents, and flow
diversion, the number of elderly patients that
can be safely treated with endovascular therapies is increasing (Figure 1 and 2).
Conclusion
The numbers of both ruptured and unruptured
cerebral aneurysms detected will continue to
increase coinciding with a rise in the elderly
population as life expectancy increases. In patients with unruptured aneurysms, a careful
estimation of life expectancy, procedural risks,
and estimation of the natural history must be
made for each patient to balance the risks of
16WWW.CNS.ORG
tions for difficult aneurysms, in particular, will
potentially improve the outcomes of elderly patients with aneurysms requiring treatment. <
REFERENCES
1
Vernooij MW, Ikram MA, Tanghe HL, et al. Incidental
findings on brain MRI in the general population. N Engl J
Med. Nov 1 2007;357(18):1821-1828.
2
Figure 1: Anterior-posterior and lateral cerebral angiogram in an 82 year old patient
presenting with diplopia and CN III palsy demonstrate a 20mm cavernous sinus aneurysm.
3
6
Sample 2001-2008. Stroke. May 2011;42(5):
Vlak MH, Algra A, Brandenburg R, Rinkel GJ. Prevalence
of intracranial aneurysms in the elderly: single-center
systematic review and meta-analysis. Lancet Neurol. Jul
experience in 63 consecutive patients. Neurosurgery.
Unruptured intracranial aneurysms--risk of rupture and
WWW.CNS.ORG Dec 2005;57(6):1096-1102; discussion 1096-1102.
14 Gonzalez NR, Dusick JR, Duckwiler G, et al. Endovascular
risks of surgical intervention. International Study of
coiling of intracranial aneurysms in elderly patients:
Unruptured Intracranial Aneurysms Investigators. N Engl
report of 205 treated aneurysms. Neurosurgery.
Morita A, Kirino T, Hashi K, et al. The natural course of
Apr;66(4):714-720; discussion 720-711.
15 Zhang QR, Zhang X, Wu Q, et al. The impact of
unruptured cerebral aneurysms in a Japanese cohort. N
microsurgical clipping and endovascular coiling on the
Engl J Med. Jun 28 2012;366(26):2474-2482.
outcome of cerebral aneurysms in patients over 60 years
Molyneux AJ, Kerr RS, Birks J, et al. Risk of recurrent
of age. J Clin Neurosci. Aug 2012;19(8):1115-1118.
16 Ryttlefors M, Enblad P, Kerr RS, Molyneux AJ.
and standardised mortality ratios after clipping or
International subarachnoid aneurysm trial of
coiling of an intracranial aneurysm in the International
neurosurgical clipping versus endovascular coiling:
Subarachnoid Aneurysm Trial (ISAT): long-term follow-up.
subgroup analysis of 278 elderly patients. Stroke. Oct
Molyneux AJ, Kerr RS, Yu LM, et al. International
2008;39(10):2720-2726.
17 Starke RM, Komotar RJ, Kim GH, et al. Evaluation of
subarachnoid aneurysm trial (ISAT) of neurosurgical
a revised Glasgow Coma Score scale in predicting
clipping versus endovascular coiling in 2143 patients
long-term outcome of poor grade aneurysmal
with ruptured intracranial aneurysms: a randomised
subarachnoid hemorrhage patients. J Clin Neurosci. Jul
rebleeding, subgroups, and aneurysm occlusion. Lancet.
2009;16(7):894-899.
18 Lubicz B, Leclerc X, Gauvrit JY, Lejeune JP, Pruvo
Sep 3-9 2005;366(9488):809-817.
JP. Endovascular treatment of ruptured intracranial
Kassell NF, Torner JC, Haley EC, Jr., Jane JA, Adams HP,
aneurysms in elderly people. AJNR Am J Neuroradiol. Apr
Kongable GL. The International Cooperative Study on the
Timing of Aneurysm Surgery. Part 1: Overall management
9
1320-1324.
13 Cai Y, Spelle L, Wang H, et al. Endovascular treatment
on sex, age, comorbidity, country, and time period: a
comparison of effects on survival, dependency, seizures,
8
Lancet. Oct 26 2002;360(9342):1267-1274.
12 Brinjikji W, Rabinstein AA, Lanzino G, Kallmes DF, Cloft
cerebral aneurysms: a study of the National Inpatient
Lancet Neurol. May 2009;8(5):427-433.
observation and intervention. For large symptomatic and giant cavernous aneurysms in patients greater than 70 years of age,
endovascular therapy is likely the best therapeutic option if feasible (particularly with flow
diversion technology). For elderly patients with
ruptured intracranial aneurysms, the majority of
good grade patients may still achieve a favorable outcome. Although both microsurgical and
endovascular therapies are both reasonable
treatment options of ruptured intracranial aneurysms, lower associated complications with endovascular therapy make this an attractive
treatment option particularly in patients with
advanced age with lesions appropriate for endovascular treatment. Continued advances in
endovascular therapy and safer treatment op-
with ruptured intracranial aneurysms: a randomised trial.
population. Stroke. Jan 2003;34(1):16-21.
subarachnoid haemorrhage, death, or dependence
7
clipping versus endovascular coiling in 2143 patients
HJ. Effect of age on outcomes of treatment of unruptured
J Med. Dec 10 1998;339(24):1725-1733.
Figure 2: Anterior-posterior and lateral cerebral angiogram on 8 month follow up after
placement of a pipeline embolization device
demonstrate near complete aneurysmal occlusion. The third nerve palsy also resolved.
Subarachnoid Aneurysm Trial (ISAT) of neurosurgical
outcome of multiple intracranial aneurysms in a defined
2011;10(7):626-636.
5
636-642.
11 Molyneux A, Kerr R, Stratton I, et al. International
Kaminogo M, Yonekura M, Shibata S. Incidence and
of unruptured intracranial aneurysms, with emphasis
4
nimodipine trial. BMJ. Mar 11 1989;298(6674):
2004;25(4):592-595.
19 Sedat J, Dib M, Lonjon M, et al. Endovascular treatment
results. J Neurosurg. Jul 1990;73(1):18-36.
of ruptured intracranial aneurysms in patients aged 65
Todd MM, Hindman BJ, Clarke WR, Torner JC. Mild
years and older: follow-up of 52 patients after 1 year.
intraoperative hypothermia during surgery for intracranial
aneurysm. N Engl J Med. Jan 13 2005;352(2):135-145.
10 Pickard JD, Murray GD, Illingworth R, et al. Effect of
oral nimodipine on cerebral infarction and outcome
Stroke. Nov 2002;33(11):2620-2625.
20 Proust F, Gerardin E, Derrey S, et al. Interdisciplinary
treatment of ruptured cerebral aneurysms in elderly
patients. J Neurosurg. Jun;112(6):1200-1207.
after subarachnoid haemorrhage: British aneurysm
17
David Krieger, MD
L. Fernando Gonzalez, MD
Is it CAS or CEA that is
not cost-effective?
T
he CREST trial leveled the playing field
between carotid artery stenting (CAS) and
carotid endarterectomy (CEA) for carotid
stenosis, showing that the primary outcome
measures of stroke, MI, and death did not differ
significantly between the two groups. Although
there was a higher peri-procedural risk of stroke
for CAS, and MI with CEA. These outcomes have
led a broad range of experts to conclude that
both CEA and CAS are comparable options for
treating carotid stenosis.1
However, there has been a debate about
the cost-effectiveness of CAS because of the
many studies that show higher costs of CAS
compared to CEA. Based on the CREST data,
Khan et al. showed that CAS is more than
35% more expensive than CAS, for similar outcomes.2 Similarly, a European study showed
that CAS is more than 35% more expensive
than CAS and points out multiple observational studies the vast majority of which agree
that CAS is not cost-effective.3 Even if CAS and
CEA have similar outcomes, the cost-effectiveness of CAS is in doubt.
When looking at why CAS is more expensive
than CEA, it is clear that in these studies it is
the price of the devices that drives the costs
of the procedure higher. For example, in the
European study mentioned before, the costs of
the hospital stay and the personnel costs are
actually higher in CEA. But while the materials cost for CEA is just over 10% of the entire
cost, in CAS it represents over 50% of the
entire cost. Similarly, in the Khan et al study,
CAS was more expensive because of the procedural costs and not because of the costs
occurring after the procedure, such as stroke,
MI, or death. The trend for higher CAS costs
persists even in countries whose governments
closely regulates prices. For example, in Japan,
where fees are set by the government, a small
study showed that CAS was more than 70%
more costly than CEA, for similar outcomes.4
Based on the studies, it would be easy to conclude that either the price of the stent needs to
come down dramatically or CAS will no longer
be a viable alternative to CEA.
On the other hand, even if the stent itself is
the major driver of costs in CAS, it is still possible that CAS is cost-effective depending on how
one calculates the inpatient CEA and CAS costs.
Using resource allocation methodology instead
of hospital accounting systems, Vilain et al. and
the CREST investigators show little difference
between the costs for CEA and CAS. While in
their study the materials still account for a large
majority of CAS cost (over 65%), the overhead
and resource utilization for CEA is more than
double that of CAS. CEA and CAS are almost
identically cost-effective in their model.5
It is clear that the price of stents and other
materials for CAS will need to come down
because their costs represent such a disproportionate amount of the total cost for the procedure. But it is possible that if they do come
down, and with the lower hospital costs associated with CAS, we may be asking ourselves in
the future if CEA—not CAS—is cost-effective. <
REFERENCES
1
Brott TG et al. CREST Investigators. Stenting versus
endarterectomy for treatment of carotid-artery stenosis.
N Engl J Med. 2010 Jul 1;363(1):11-23. Erratum in:
N Engl J Med. 2010 Jul 29;363(5):498. N Engl J Med.
2010 Jul 8;363(2):198.
2
Khan AA et al. Cost-effectiveness of carotid artery
stent placement versus endarterectomy in patients
with carotid artery stenosis. J Neurosurg. 2012
Jul;117(1):89-93.
3
Janssen MP et al. Carotid stenting versus carotid
endarterectomy: evidence basis and cost implications.
Eur J Vasc Endovasc Surg. 2008 Sep;36(3):258-64;
> it is still possible that CAS is cost-effective
depending on how one calculates the inpatient
CEA and CAS costs. <
discussion 265-6.
4
Sadamasa et al. Cost Comparison of Carotid
Endarterectomy versus Carotid Stenting in Japan. No
Shinkei Geka. 2013 Jan;41(1):31-5.
5
Vilain KR et al. Costs and cost-effectiveness of
carotid stenting versus endarterectomy for patients
at standard surgical risk: results from the Carotid
Revascularization Endarterectomy Versus Stenting Trial
(CREST). Stroke. 2012 Sep;43(9):2408-16.
18WWW.CNS.ORG
Christopher Farrell, MD
Steven N. Kalkanis, MD
Brain Tumor Management in the Elderly –
Too Old to Treat?
C
onventionally, “elderly” has been defined
as persons exceeding 65 years of age;
however, in this era of improved medical
care and increasing average lifespan, a purely
chronological definition seems conspicuously
oversimplified.1 While determining who is “old”
will always remain a matter of perspective,
the fact of the matter is the incidence of most
benign and malignant intracranial tumors
increases with advancing age. Nearly half of
patients diagnosed with glioblastoma (GBM)
are 65 years of age or older and the number
of new cases in the elderly is expected to at
least double over the next two decades as a
result of the population aging phenomenon.2 As
we prepare for this swelling of baby boomers,
WWW.CNS.ORG sometimes referred to as the “Silver Tsunami”,
we take on the contemporary challenge of brain
tumor management in the elderly focusing on
the existing data and unresolved questions.
When compared to younger patients,
elderly brain tumor patients have a disproportionately increased incidence of medical
comorbidities and ancillary variables that
make their care more complex including
reduced access to caregivers and practical
transportation impediments.3 Unfortunately,
in this population for whom careful patient
selection is perhaps most important, there is
a lack of high-quality data due to the deliberate
exclusion of elderly patients from most clinical
trials leaving the treating neurosurgeon with
relatively little information upon which to base
treatment recommendations, including the
extent of surgery that is most appropriate and
the efficacy and toxicity of adjuvant therapies.
Glioblastoma represents the most common
form of brain tumor in the elderly and population-based studies unmistakably demonstrate
that this group is not managed in the same
way as younger patients. Patients over the
age of 65 are more likely to undergo surgical
biopsy and palliative care alone and only about
10-20% of patients receive adjuvant chemotherapy.4-6 This variance in care suggests that
elderly patients must also overcome physician
prejudice against more aggressive therapies,
a common observation amongst systemic cancers.7 While a series of retrospective studies
demonstrated survival benefits in the elderly
more closely approaching those observed in
younger patients following multimodal treatment of GBM, the generalizability of these
results is limited as these studies have typically only included patients with excellent
performance status and reduced comorbidity.
Simple extrapolation of treatment practices
that are effective in younger patients may not
be appropriate. A tailored approach incorporating the relative benefits and risks of surgery,
radiotherapy and chemotherapy, combined
with an improved assessment of operative risk
and physiologic reserve seems most appropriate in the treatment of elderly patients.
Radiotherapy is considered a critical component of GBM treatment; however, advanced
age has been associated with increased
radiation-toxicity including brain atrophy and
dementia, possibly as a result of pre-existent
vascular compromise in the elderly.8 While the
incidence of these events is correlated with
19
> Nearly half of patients diagnosed with glioblastoma (GBM) are 65
years of age or older and the number of new cases in the elderly is
expected to at least double over the next two decades as a result of
the population aging phenomenon.2 As we prepare for this swelling
of baby boomers, sometimes referred to as the “Silver Tsunami”, we
take on the contemporary challenge of brain tumor management in the
elderly focusing on the existing data and unresolved questions. <
the volume of irradiated tissue, earlier studies for patients with malignant glioma were
performed using whole-brain radiation therapy
as opposed to the more conformal regimens
used currently. In 2007, Kieme-Guibert et al.
convincingly demonstrated that survival is
lengthened using postoperative conformal
radiation for GBM compared to supportive
care alone in elderly patients with good Karnofsky performance status.9 Importantly, no differences in quality of life or cognitive function
were observed. Given the shortened expected
length of survival for elderly patients, there has
been considerable effort to determine whether
a shortened course of radiotherapy may
achieve similar results while reducing the burden of treatment. The Nordic trial compared
standard 6 week (60Gy) radiation to a hypofractionated radiation schedule (34Gy over
2 weeks) and found a survival advantage for
elderly patients treated with short course RT,
possibly as a result of more patients completing the shorter prescribed radiation course.10
While standard radiation may be appropriate
for extremely high-performing elderly patients
with GBM, a shortened radiation course certainly seems reasonable and better tolerated
in more vulnerable and frail patients.
Many chemotherapeutics, including bevacizumab, have been associated with increased
serious Grade 3-4 toxicity in elderly patients,
possibly as a result of differences in drug
metabolism and bioavailability.11 The Nordic
trial, along with the German Cancer Society
NOA-08 trial, attempted to determine the
efficacy and toxicity of temozolomide chemotherapy in elderly patients with GBM.12 These
prospective randomized trials demonstrated
that treatment with temozolomide alone following surgical intervention is well-tolerated
and achieves survival times similar to those
observed with radiotherapy. The question
remains whether the approach toward adjuvant treatment of GBM in the elderly can be
further personalized on the basis of tumor biomarker analysis. The methylation status of the
MGMT gene promoter has been shown to be a
positive predictor of temozolomide response,
and elderly patients have similar rates of
MGMT promoter methylation compared to
younger cohorts.13, 14 This suggests that elderly
patients with poorer performance status may
be candidates for short course RT or chemotherapy alone based on their MGMT status.2
Surgery for malignant gliomas remains
somewhat contentious for any cohort. The
potential survival advantages of an increased
extent of resection in the elderly must be
weighed against the likelihood of surgical
morbidity and prolonged recovery period.
Several small studies have demonstrated
that in carefully selected patients, aggressive
surgical intervention with complete resection
achieves improved survival with low rates of
adverse events.15,16 However, increased surgical morbidity with advancing age has been
consistently demonstrated for major surgical
procedures.3,17 Performance status provides
some measure of physiologic reserve, however, it likely represents an insufficient measure of operative risk. The Multidimensional
Geriatric Assessment (MGA) and Comprehensive Geriatric Assessment Questionnaire (CGA)
have been frequently implemented in the care
of elderly cancer patients and used to guide
therapy administration.18,19 While the ability
of these instruments to stratify operative risk
in elderly patients with brain tumors has yet
to be validated, they clearly add significant
information and may be beneficial in better
determining which subpopulations are likely
to benefit from complete surgical resection in
terms of survival, reduced surgical morbidity,
and retained quality of life.19
The incidence of benign intracranial tumors
also increases with age and even less quality
evidence is available to guide neurosurgeons
as to the best management strategy. Perhaps
the most attention to this issue has been
focused on meningiomas where their incidence is 3.5 times higher in patients older than
70 years than in younger patients.17 While the
options may be limited in those suffering from
debilitating mass effect, for many of these,
lesions expectant management, radiosurgery,
and surgical resection may represent reason-
20WWW.CNS.ORG
able alternatives. There has been considerable interest in determining the operative risks
associated with meningioma resection in the
elderly with the results in the literature varying widely, including perioperative mortality
rates ranging from 1.8-45%.17 Several recent
large database analyses have revealed a more
likely accurate reflection of the general risks
associated with meningioma resection in the
elderly. Bateman et al. reported that elderly
patients were three times as likely to die in
the hospital (4%) after meningioma resection
compared to the non-elderly and five times as
likely to have an adverse outcome (death or
discharge to a facility).17 Using the Veterans
Affairs’ (VA) National Surgical Quality Improvement Program (NSQIP) database, Patil et al.
reported increased 30-day mortality rates
in the elderly of 12% compared to 4.6% in
younger patients and an overall complication
rate of 29%.20 Even after controlling for tumor
location, preoperative comorbidities and
American Society of Anesthesiologists (ASA)
class, the elderly had a threefold increase in
perioperative mortality. Despite their limitations, these studies clearly show that the risks
of meningioma resection are increased in the
elderly and the decision to pursue elective
surgical treatment should be carefully deliberated. Fortunately, the risks of alternative
therapies such as stereotactic radiosurgery do
not seem to be significantly increased in the
elderly.21 Although tumor volume and location
are associated with increased complication
rates, age does not appear to be a significant
determinant of radiosurgery-induced complications. For elderly patients, radiosurgery may
represent the preferred treatment strategy for
actively growing tumors without debilitating
mass effect.
The management of intracranial tumors in
the elderly remains complex but the literature
supports the commonsense perception that
there exist subpopulations among the elderly
who may benefit from aggressive surgical intervention and adjuvant therapies, both in terms of
WWW.CNS.ORG survival and quality of life. With the older segment of the population growing faster than any
other age group, the inevitable “Silver Tsunami”
demands we more rapidly define these subgroups to provide our patients the best care. <
REFERENCES
1
2
Orimo H. [Reviewing the definition of elderly]. Nihon
4
7
9
glioblastoma. N Engl J Med. Mar 10 2005;352(10):
997-1003.
14 Gerstner ER, Yip S, Wang DL, Louis DN, Iafrate AJ,
biomarker in elderly patients with newly diagnosed
management of elderly patients with glioblastoma.
glioblastoma. Neurology. Nov 3 2009;73(18):
Audisio RA, Zbar AP. Updates in surgical oncology
1509-1510.
15 Vuorinen V, Hinkka S, Farkkila M, Jaaskelainen J.
for elderly patients. Crit Rev Oncol Hematol. Sep
Debulking or biopsy of malignant glioma in elderly
2002;43(3):209-217.
people - a randomised study. Acta Neurochir (Wien).
Barnholtz-Sloan JS, Williams VL, Maldonado JL, et
Jan 2003;145(1):5-10.
al. Patterns of care and outcomes among elderly
16 Grossman R, Nossek E, Sitt R, et al. Outcome of Elderly
individuals with primary malignant astrocytoma.
Patients Undergoing Awake-Craniotomy for Tumor
Gulati S, Jakola AS, Johannesen TB, Solheim O.
Resection. Ann Surg Oncol. Dec 4.
17 Bateman BT, Pile-Spellman J, Gutin PH, Berman MF.
Survival and treatment patterns of glioblastoma in the
Meningioma resection in the elderly: nationwide
elderly: a population-based study. World Neurosurg.
inpatient sample, 1998-2002. Neurosurgery. Nov
Lowry JK, Snyder JJ, Lowry PW. Brain tumors in the
2005;57(5):866-872; discussion 866-872.
18 Basso U, Tonti S, Bassi C, et al. Management of Frail
elderly: recent trends in a Minnesota cohort study. Arch
and Not-Frail elderly cancer patients in a hospital-based
Neurol. Jul 1998;55(7):922-928.
geriatric oncology program. Crit Rev Oncol Hematol.
Bouchardy C, Rapiti E, Fioretta G, et al. Undertreatment
strongly decreases prognosis of breast cancer in elderly
8
gene silencing and benefit from temozolomide in
Batchelor TT. Mgmt methylation is a prognostic
Nov;78(5):518-526.
6
707-715.
13 Hegi ME, Diserens AC, Gorlia T, et al. MGMT
Laperriere N, Weller M, Stupp R, et al. Optimal
J Neurosurg. Apr 2008;108(4):642-648.
5
randomised, phase 3 trial. Lancet Oncol. Jul;13(7):
Ronen Igakkai Zasshi. Jan 2006;43(1):27-34.
Cancer Treat Rev. Jun 19.
3
malignant astrocytoma in the elderly: the NOA-08
May 2008;66(2):163-170.
19 Repetto L, Fratino L, Audisio RA, et al. Comprehensive
women. J Clin Oncol. Oct 1 2003;21(19):3580-3587.
geriatric assessment adds information to Eastern
Gomez-Millan J. Radiation therapy in the elderly:
Cooperative Oncology Group performance status in
more side effects and complications? Crit Rev Oncol
elderly cancer patients: an Italian Group for Geriatric
Hematol. Jul 2009;71(1):70-78.
Oncology Study. J Clin Oncol. Jan 15 2002;20(2):
Keime-Guibert F, Chinot O, Taillandier L, et al.
Radiotherapy for glioblastoma in the elderly.
N Engl J Med. Apr 12 2007;356(15):1527-1535.
10 Malmstrom A, Gronberg BH, Marosi C, et al.
Temozolomide versus standard 6-week radiotherapy
versus hypofractionated radiotherapy in patients
older than 60 years with glioblastoma: the
494-502.
20 Patil CG, Veeravagu A, Lad SP, Boakye M. Craniotomy
for resection of meningioma in the elderly: a
multicentre, prospective analysis from the National
Surgical Quality Improvement Program. J Neurol
Neurosurg Psychiatry. May;81(5):502-505.
21 Pollock BE, Stafford SL, Link MJ, Garces YI, Foote RL.
Nordic randomised, phase 3 trial. Lancet Oncol.
Single-fraction radiosurgery for presumed intracranial
Sep;13(9):916-926.
meningiomas: efficacy and complications from a
11 Aprile G, Ferrari L, Fontanella C, Puglisi F. Bevacizumab
in older patients with advanced colorectal or breast
22-year experience. Int J Radiat Oncol Biol Phys. Aug
1;83(5):1414-1418.
cancer. Crit Rev Oncol Hematol. Dec 19.
12. Wick W, Platten M, Meisner C, et al. Temozolomide
chemotherapy alone versus radiotherapy alone for
21
Normal Pressure Hydrocephalus:
A Multidisciplinary Approach
Jason M. Schwalb, MD,
FAANS, FACS
I
diopathic Normal Pressure Hydrocephalus
(iNPH) was first described in 1965 by Adams
and Hakim as a syndrome affecting older people with ventriculomegaly. These people have a
triad of symptoms: gait apraxia, dementia, and
urinary incontinence.
It has since been recognized that not all
patients with iNPH have the full triad (although
all seem to have gait abnormalities). In spite of
the fact that the pressure seems to be normal
on spinal tap, these symptoms get better (or at
least stop getting worse) with diversion of the
spinal fluid with a shunt.
The diagnosis of iNPH is difficult. There is no
gold standard in determining if the syndrome is
a cause for the symptoms, other than response
to shunting. If someone does not respond to
shunting, it is often unclear whether this is
because they never had the syndrome in the
first place, they have other conditions which
are the cause of their symptoms, the shunt was
placed too late to help, or there is a malfunction of the shunt system. In addition, there is
significant concern about placebo effect, as
evidenced by the example of a patient demonstrating improvement of gait after a sham lumbar puncture.1 There is no consistent pathology
on autopsy studies of patients who respond to
shunting. As a result, many neurologists do not
believe in the existence of this syndrome.
Not surprisingly, it is impossible to get a fair
idea of how common this syndrome is. The likelihood of other conditions or combinations of
conditions, causing the triad of symptoms associated with NPH is not insignificant. In a small
survey of extended care facilities in Virginia,
19% of residents under the age of 85 had the
full iNPH triad.2 This is probably more an issue
of the prevalence of these symptoms from multiple causes in an aging population rather than
an epidemic of NPH in Virginia nursing homes.
Making a diagnosis involves consideration
and treatment of other potential causes of the
symptoms. Because these symptoms are so
common in the elderly, Occam’s razor cannot
be applied. While the referral for workup for
iNPH is usually directly from the primary care
physician to the neurosurgeon, the involvement
of a clinician with experience in cognitive neurology is essential.
Since 2009, we have run a multidisciplinary
clinic at Henry Ford West Bloomfield Hospital,
and have learned many lessons from our experience:
• “Just because you haven’t seen it, doesn’t
mean it hasn’t been in your clinic.” Many
patients presenting with gait disorders state
they do not have any cognitive difficulties,
but are found to have impairment on the
Montreal Cognitive Assessment (MoCA) and
other measures. Unfortunately, we have also
seen patients shunted by other neurosurgeons who, upon being seen by one of our
neurologists, are diagnosed with Pick’s Disease or other rapidly progressive dementias.
Therefore, we perform a structured history
and physical examination for behavioral and
cognitive symptoms on all elderly individuals
presenting with gait complaints.
• About 40% of our patients referred to us for
evaluation are found to have alternative
causes for their symptoms, many of which
can respond to treatment. Usually the culprit is inappropriate medications with anticholinergic side effects, but we also have
patients who have done quite well after we
treat their sleep apnea, hypoparathyroidism,
hypovitaminosis D, excessive alcohol intake
or cervical spondylitic myelopathy.
• Cast a wide net. Because the diagnosis of
dementia is associated with such poor outcomes, some have advocated shunting all
patients with ventriculomegaly who have
typical gait symptoms prior to cognitive and/
or urinary symptoms.3 Although this has a
better positive predictive value than high
volume lumbar puncture, not performing
extensive analysis on urine, blood, and CSF
can lead one astray. We have two patients
who were found to have paraneoplastic syndromes as the cause of their symptoms on
the basis of their CSF analysis.
Rhonna Shatz, DO, FAAN
• Finding an alternative diagnosis does not
mean that the patient doesn’t also have
NPH. Sometimes, after optimization of other
issues, the patient still has symptoms that
respond to high volume lumbar puncture or
extended lumbar drainage. We still give such
patients the opportunity to have a shunt
placed. In fact, one of our most thankful families is that of a gentleman with longstanding
Alzheimer’s Disease (AD) who subsequently
developed a typical gait apraxia. He has had
about three years of benefit in his gait and
improved cognitive interactions with his family. On the other hand, one should be conscious of the potential outcomes of shunting
such patients. We know of one patient with
AD who became an escape risk once his gait
improved after shunting, much to the chagrin of his caregivers.
We tend to be liberal in offering surgery to
patients coming to us with symptoms consistent with iNPH, once we have optimally
treated other conditions that can cause the
triad of symptoms. In spite of the considerable complication rate associated with shunting (15-20% with programmable valves), we
are far more concerned about missing
patients who might benefit from shunting
than in obtaining the highest response rates.
While this multidisciplinary approach is labor
intensive, we feel it results in the best care
for these complex patients. <
References
1
Gupta A, Lang AE. Potential placebo effect in assessing
idiopathic normal pressure hydrocephalus. J Neurosurg.
2011 May;114(5):1428-31. doi: 10.3171/2010.12.
JNS10106. Epub 2011 Jan 21.
2
Marmarou A, Young HF, Aygok GA. Estimated incidence
of normal pressure hydrocephalus and shunt outcome
in patients residing in assisted-living and extended-care
facilities. Neurosurg Focus. 2007;22(4):E1.
3
Burnett MG, Sonnad SS, Stein SC. Screening tests for
normal-pressure hydrocephalus: sensitivity, specificity,
and cost. J Neurosurg. 2006;105:823-9.
22WWW.CNS.ORG
Featured articles
Electronic Health Record (EHR)
Neurosurgeons Define Meaningful Use
E –Electronic, Efficient, Effective, Egregious, Essential
H –Health, Helpful, Hurtful, Horrendous, Happening
R –Record, Report, Rational, Repudiated, Remedy
Deborah L. Benzil, MD
Srinivas Prasad, MD
Imagine the following (or any of
a millions similar) scenarios:
Y
our aging parents have decided to take
an adventurous cross-country trip to see
all the wonders of their dreams such as
the Grand Canyon and Old Faithful. Just out
of Denver, your father develops a gripping
epigastric/chest pain and your mother drives
him to the nearest hospital. While his EKG is
wildly abnormal (he has had 7 prior stents) it can
easily be compared with and found unchanged
compared to several prior accessed through
EHR and he is shortly sent on his healthy way.
The culprit, easily cured with Maalox, is most
likely the roadside greasy spoon where your
parents stopped for lunch. Soon they reach the
Canyon and post their glorious photographs for
all the children and grandchildren to see.
Is there any inherent value, in terms of
cost or quality of care, of an EHR? For those
neurosurgeons who have been relatively early
adopters of this technology, I think the answer
would be an unequivocal yes. At present, the
advantages are many, including legibility, consistency, accessibility and more. The age of
digital medicine is here to stay. Unfortunately,
too much of the development of this technol-
WWW.CNS.ORG ogy has sidestepped physician input and the
full promise of EHR cannot be achieved without it. This applies not just to software and applications but also to the CMS EHR incentive
program. The purpose of this article is to set a
critical framework of ideal requirements that
we feel EHR should be required to offer in the
near future.
1.Privacy
2. Universal interoperability
3. Portability (across computer platforms and
devices)
4.Queriability
5.Speed
6.Flexibility
7. Decision/Management Support
8. Universal Final Chart
Let us consider each of these individually.
Privacy
There is perhaps no more important concept
for EHRs of the future than privacy. This is not
just the simple confidentiality that has become
an overused mantra of HIPAA, but also the confidence that individual data will not be used
(abused) by insurance companies, employers
and the like. It ensures that relevant data –
nothing more and nothing less – is available
to each of the relevant parties participating in
healthcare delivery and monitoring.
Universal Interoperability
It is critical that for each patient, their labs,
reports, and imaging be fully interchangeable
across locations, practices, and settings. For
example, a diabetic may have glucose and A1C
readings done at home, PMD and endocrine
offices, the ER, and also the hospital. It must
be possible for all of these to be “dumped”
into a common results folder, not unlike we
can upload photographs of all places, dates,
and photographers into an on-line site such as
Picasa. This is particularly critical when a
patient is transferred in the acute setting
where critical data obtained at Hospital #1 is
repeated-at expense and time-at Hospital #2.
Unlike countries such as the United
Kingdom who have solved this problem by
choosing a single EHR that all facilities (even
those outside the HHS) must use, the US
health care system demands this be arbitrated
in the court of free market competition.
The two need not be mutually exclusive.
In the world of electrical appliances, many
companies compete to sell you their hairdryers,
23
televisions, food processors, and more. And
yet each of these devices must function (in the
US) using a standard 2 or 3 prong AC power
plug. The DICOM standard was developed
to address interoperability between imaging
devices so that all radiographic images are
formatted in the same fashion regardless of
vendor or imaging modality. The same not only
can but must apply to our future EHRs.
Portability
One of the great values of even the current
EHR systems is the rapid access to data from
a variety of locations. Most of us have utilized
the advantages of writing hospital progress
notes from our office or homes, accessing
emergency images from remote locations,
detailing and documenting phone call backs
done at night or on weekends, or reviewing
history/medications/allergies on new patients.
However, current systems remain significantly
flawed in these and other applications. For
example, some systems remain stubbornly
incompatible with Apple operating systems or
require enormous investment to overcome this
hurdle (this is especially true with PACS systems). This is unacceptable and the burden for
compatibility must rest with the manufacturers
and not the individual users.
Queriability
entry, built-in document generation and rich
interfaces will enable rapid, secure and more
meaningful aggregation and creation of medical content.
Flexibility
Care for a single patient is often delivered by
a variegated group of participants – specialists, physician-extenders, and residents – all
playing a different role in the composition of
care. The interfaces by which each agent participates in care cannot be “one-size-fits-all”.
Each user is interested in seeing different information and makes specific contributions.
The medical record for a single patient needs
to be imagined as a multi-dimensional, rich
canvas on which many agents contribute different but predictable pieces. Interfaces need
to be flexible enough to allow customization
for each user to facilitate efficient acquisition
of these predictable pieces. Cardiologists may
routinely need access to EKGs, specific labs
and vital sign values. They will need a different
interface design than a neurosurgeon to maximize efficiency. One could argue that different
neurosurgeons might prefer different interface
designs and even that a single neurosurgeon
may want a different interface in the inpatient
setting than he/she would use in the outpatient setting.
One critical value of electronic data should
be the ability to utilize that data for approved,
clinical research projects. Most current EHRs
have little or no ability to search and extract
data based on diagnosis, medication, and
laboratory value or similar. These systems
should make conducting research easier,
not harder. Designs that are sensitive to this
requirement will facilitate uniform collection of
outcome measures that are diagnosis-specific.
Decision/Management Support
Speed
1. “All admissions will get screening lower extremity ultrasounds within 24 hours of admission and weekly ultrasounds thereafter”
2.“All suspected spine infections will get
admission ESR, CRP, ID Consult, biopsy
and pain management consultation”
Clearly for all of us, including our patients, time
is money. While privacy precautions are essential and checks need be in place to prevent
errors, speed of use must be a high priority.
Easy and secure access, multi-modality data-
With the proliferation of clinical guidelines
and pathways, it is increasingly challenging
to verify compliance with these ever-changing
standards. EHRs offer the capacity to maintain
pathway-compliant care. As institutional policies are developed, logic can be embedded in
EHRs to trigger certain actions or reminders.
A few simple examples highlight the value of
this feature:
3. “Sodium values less than 132 will trigger
entry into the daily progress note of the
phrase ‘hyponatremia’ to maintain compliance with complexity coding requirements”
4.“All patients with cervical spondylotic
myelopathy will trigger a reminder to inquire
about participation in an ongoing trial”
5. PQRI variables will be verified to be complete before a patient can be discharged or
a document can be completed.
While EHRs will not supercede clinical decision-making, they can have logic built into
them to maintain consistency, compliance
and efficiency. In an emerging era of pathwaycompliance, this may be one of the most valuable features of an ideal EHR.
Universal Dynamic Chart
As we have moved increasingly into the digital era, the need for a “current chart”, often
printed, has not disappeared. Such a record
may be needed for a variety of reasons and
while these need not resemble the traditional
paper chart, some standard must be established so that safe and comprehensive transmission of information can be assured.
CMS is working to insure their definition of
meaningful use in the world of EHR, we pose
these equally important criteria for insuring
the world of digital medicine truly brings financial saving, efficiency, and improved quality of
care for our patients. <
WWW.CNS.ORG 24WWW.CNS.ORG
24
Neurosurgeons Providing
a Strong Voice at the AMA
Katie O. Orrico, JD
Ann Stroink, MD
Meet the Delegation
W
ith greater than 200,000 members,
the American Medical Association
(AMA) is one of the most influential
lobbying groups on Capitol Hill. Its efforts provide
a voice for the larger medical community in our
nation’s capital, and its policies affect how
physicians practice on a day-to-day basis. Though
small in numbers, the American Association of
Neurological Surgeons (AANS) and Congress of
Neurological Surgeons (CNS) have found ways
to increase the size of their delegation, allowing
neurosurgery to exert greater influence on AMA
policies and actions. At the recent November
AMA meeting, nine neurosurgeons represented
the AANS, the CNS, and the interests of
neurosurgery. With only nine ambassadors
for organized neurosurgery, covering all of the
caucuses, committees, and House of Delegates
(HOD) floor action, can be chaotic. Delegates
often find themselves running between
meetings, or juggling to cast a vote, to ensure
that the voice of neurosurgery is heard.
WWW.CNS.ORG Organized Neurosurgery’s AMA Delegation celebrating Mark Kubala’s Distinguished Service Award (Left to Right:
Katie Orrico, Phil Tally, Maya Babu, Mark Kubala, John Ratliff, Monica Wehby, Krystal Tomei, Zach Litvack, Ann
Stroink; Not Pictured: Peter Carmel.
Peter W. Carmel, MD, Immediate Past
President of the AMA
Dr. Carmel, a pediatric neurosurgeon from Newark, brings a wealth of experience to the neurosurgery delegation. Over the last twenty years,
he served as chair of the AMA Specialty and
Service Society (SSS), chair of the AMA Council
on Long Range Planning and Development, and
President of the AMA Foundation. Most recently,
Carmel served as the 166th AMA president. Dr.
Carmel brings his years of leadership experience
in the AMA to help the steer the neurosurgery
delegation. On behalf of neurosurgery, he brings
a well-respected voice to the HOD.
Monica C. Wehby, MD, AMA Board of
Trustees
Since the Texas Medical Association Medical
Student Section elected her chair, Dr. Wehby
has been active in the AMA HOD. Currently serving on the Board of Trustees, Dr. Wehby, a pastpresident of the Oregon Medical Association,
provides organized neurosurgery with a voice
within the leadership of the AMA. In addition
to working with the AMA, this pediatric neurosurgeon is the Council of State Neurosurgical
Societies’ (CSNS) Northwest Quadrant Regional
Director and on the AANS Board of Directors.
25
Mark J. Kubala, MD, AANS Delegate
Dr. Kubala, a Texan, has been highly active in
organized medicine for nearly 50 years. At the
November meeting, the AMA recognized Dr.
Kubala’s lifetime of service by bestowing upon
him the Distinguished Service Award. During
the presentation, AMA president Dr. Jeremy
Lazarus stated, “Dr. Kubala embodies the essence of what it means to be a physician.” Go
to the following link: http://www.ama-assn.
org/ama/pub/about-ama/our-people/the-federation-medicine/specialty-society-ballot.page
to view the award presentation.
Dr. Kubala receiving the Distinguished Service Award for
Meritorious Service in the Art and Science of Medicine.
Ann R. Stroink, MD, AANS Delegate
In November, Dr. Stroink, a past-president of
the Illinois State Neurosurgical Society, had
the privilege of serving on the HOD’s legislative reference committee. On it, she listened to
testimony on, proposed amendments to, and
made recommendations on resolutions to the
HOD. She is also an active participant in the
Coalition of State Medical and National Specialty Societies, which regularly brings resolutions before the HOD.
Krystal L. Tomei, MD, MPH, PGY-7,
AANS Delegate (Resident and Fellow Section)
Dr. Tomei is an AANS-endorsed delegate from
the Resident and Fellow Section. Currently residing in New Jersey, Dr. Tomei is a budding
leader in neurosurgery and provides a young,
powerful voice in the AMA, where she serves
on the AMA’s Council of Medical Education.
Representing the future of neurosurgery, Dr.
Tomei is demonstrating herself to be a strong
leader and advocate for neurosurgeons.
John K. Ratliff, MD, AANS Alternate
Delegate
An Associate Professor at Stanford University
Medical Center, Dr. Ratliff serves neurosurgery in multiple roles. During his tenure as
an alternate delegate to the AMA, he has had
the opportunity to serve on the HOD’s legislative reference committee. Away from his AMA
responsibilities, Dr. Ratliff has more than 100
publications. He is also the vice chair of the
AANS/CNS Quality Improvement Workgroup
and the AANS’ Advisor to the AMA-Specialty
Society Relative Update Committee.
Phillip W. Tally, MD, CNS Delegate
Dr. Tally, a past-president of the Florida Neurosurgical Society, brings a knowledgeable voice
to the HOD. The Alabama-native is currently the
chair of neurosurgery’s AMA delegation, and is
a past chair of the AMA Specialty and Service
Society (SSS). Dr. Tally is a recognized expert on
health information technology issues, and serves
on the AMA’s Health Information Technology
Advisory Panel. He also serves as the CSNS’ parliamentarian, and brings these skills to the AMA.
Zachary N. Litvack, MD, MCR,
CNS Alternate Delegate
Dr. Litvack is the co-director of The Endoscopic
Pituitary and Anterior Skull Base Surgery Program at The GW Medical Faculty Associates.
He also works as an assistant professor of
neurosurgery and otolaryngology at George
Washington University. Dr. Litvack’s research
has been recognized throughout neurosurgery,
as he has received awards from the National
Brain Tumor Foundation and the AANS/CSNS.
Highly involved in organized medicine, he is
the assistant editor of Self-Assessment in
Neurological Surgery (SANS) and serves on the
executive committee of the National Neurosurgery Quality & Outcomes Database (N2QOD).
Maya A. Babu, MD, MBA, PGY-3,
Resident and Fellow Section (Minnesota)
A Minnesota-endorsed Resident and Fellow
Section delegate, Dr. Babu has worked closely
with neurosurgery over the past two years.
Like Dr. Tomei, she provides a fresh, energetic
voice to the delegation. She is the 2012-2013
Resident and Fellow Section appointee on the
AMA Council on Legislation and serves on the
Resident Fellow Section Governing Council.
In 2013, Dr. Babu is running for the residentfellow position on the AMA Board of Trustees.
Katie O. Orrico, JD, AMA Staff Liaison
Katie Orrico has spent nearly 28 years
advocating on behalf of neurosurgery. As the
AANS/CNS Washington Office Director and
AMA Staff Liaison, she helps organize and
guide the neurosurgical delegation. In addition
to directing the Washington office, Ms. Orrico
works with the AANS Political Action
Committee, NeurosurgeryPAC. With her
expertise, the delegation is strongly positioned
to represent neurosurgery. <
WWW.CNS.ORG 26WWW.CNS.ORG
26
Locum Tenens, My Solution
to Physician Burnout
Duane Gainsburg, MD
I
n early 2004, I was at the height of my career
as a neurosurgeon in solo practice, but I was
also well on my way to clinical depression. I
was angry and couldn’t relax, and I was always
irritated. Even a few days off didn’t help because
of the mountain of phone calls and paperwork
waiting for me upon return to work. I asked
myself, is this burnout?
Coincidentally, I happened to meet a neurosurgeon practicing Locum Tenens that was
happy with his work-life balance. I signed up for
a weekend trial as a locum neurosurgeon, then
a week trial, and then I looked at my wife who
was also my office manager, and asked, “Why
are we doing this?” A month later we closed the
office.
Stress and burnout are often lumped together, but they are distinct processes. Unlike
stress which is associated with over engagement, burnout is characterized by disengagement, blunted emotions, depression, and
exhaustion, which affects motivation and
drive, and demoralization. Stress produces
a sense of urgency and hyperactivity, while
burnout produces a sense of helplessness and
hopelessness.
WWW.CNS.ORG This country is losing the experience, skill
and wisdom of senior physicians because of
burnout, yet the problem is not discussed
openly among physician peers, and there’s
a paucity of relevant psychological services
for physicians. My personal solution: Locum
Tenens.
I made the adjustment from working fulltime to Locum Tenens through support and
access to other locum doctors, and now I
honestly look forward to my monthly 10-day
assignments. Many productive people don’t
do well when jerked into full retirement, and
I have the best of both worlds: steady, satisfying work, on my terms of time and intensity,
predictable income, and freedom from government/insurance company machinations
and hospital political intrigues. The agreement (contract) with the hospital is clear and
short term, and the supply-demand balance
for Locum Tenens doctors in my specialty is
currently in my favor. When at home, I have
the freedom to not answer the phone, the certainty that the concert, nice restaurant meal,
or the weekend away won’t be interrupted, and
the security that my income checks will be as
expected and on time. The conflict between
family and profession is now moot.
Another issue is a sense of financial fairness.
My income doesn’t depend on “production
units” – euphemism for “you get more income
if you see more patients, do more complicated
procedures...” My value to the hospital depends
on my professional ability, and availability. What
used to be uncompensated time talking with patients and their families both in hospital and in
the office is now mutually rewarding. Getting up
at night to see an emergency room patient often
used to be uncompensated time, while taking
away from needed rest for the following day’s
frenetic activities.
Now, I’m paid for the time spent taking care
of folks, rather than for how much I can bill
for this or that procedure. It’s a four-way win:
families benefit from improved relationships
with their doctor, I benefit professionally from
the satisfaction of providing excellent care no
matter how long it takes, the hospital benefits
by providing continuity of care and consistent
coverage, and I benefit financially by the time I
spend in direct patient contact, whether in the
operating room, emergency room, intensive
care unit, etc.
In private practice, I had the pervading
sense that because of all the distractions and
competing agendas I wasn’t able to deliver the
best care I was capable of. There was an underlying layer of guilt, and of missed professional
opportunity. In speaking with many physicians
in many physician lounges, I believe many still
have this pessimistic view.
By moving my career into the locum tenens
venue, these are issues of the past. <
27
A Retrospective Study of a Novel Operative
Documentation Education Program with an
Emphasis on Coding: A New Addition to Modern
Neurosurgery Residency Training?
Paul E. Kaloostian, MD
Han Chen, MD
Martina Stippler, MD
in lack of resident operative documentation and coding skills after residency with significant loss of reimbursement in practice.3-5
We at the University of New Mexico Medical Center, the only Level
I trauma center in the state and surrounding region, attempted to address this issue by analyzing the effect of a standardized monthly coding course over twelve months on one resident’s operative dictations.
We studied the effect of this education on resident documentation and
whether this can fulfill ACGME requirements of practice-based learning
and systems-based practice.
METHODS
INTRODUCTION
S
urgical training has changed dramatically over the last few
decades1, with novel surgical techniques changing surgical
training programs. 1 The American Association for Graduate
Medical Education (ACGME) implemented six core competencies into all
residency programs, and training programs have had to adapt. These core
competencies include patient care, interpersonal and communication
skills, medical knowledge, professionalism, practice-based learning and
improvement, and systems-based practice. The ACGME defines practicebased learning as: investigate and evaluate the care of patients, appraise
and assimilate scientific evidence, and continuously improve patient care
based on constant self-evaluation and lifelong learning.6 The ACGME
defines systems-based practice as: Residents must demonstrate an
awareness of and responsiveness to both the larger context and system
of health care as well as the ability to effectively call on system resources
to provide care that is of optimal value.6
Lack of knowledge about coding, reimbursement, and documentation
lead to revenue loss, legal, business, and administrative ramifications.3-5
Current resident training does not include a standardized operative documentation educational program with emphasis on coding, which results
Following Institutional Review Board (IRB) approval, sixty operative notes
were randomly obtained; thirty before instituting and thirty notes after
completing the educational course. The one-hour monthly course with
the coding team was taught by one faculty member (senior author, MS),
during which we reviewed material on neurosurgery operative procedure
dictation according to the American Medical Association CPT Coding
Textbook (AMA, 2012). This was followed by an open discussion of errors
noted by the coding team and example-case review to apply this learning
(Figure 1).
Figure 1.
Operative Documentation Errors Before and After
Operative Notes
(60 notes)
Reviewer 1 Reviewer
Errors
2 Errors
Median
Errors
Before Course (30)
32
31
30
After Course (30)
19
20
19.5
Stats (ANOVA)
P<0.05
P<0.05
P<0.05
The randomly-selected operative notes from the senior neurosurgery
resident were graded by our neurosurgery coder in a standardized blind
fashion, with points assigned for each coding error and the results tallied
in a blinded fashion by two physicians.
RESULTS:
The median number of note errors before and after were 31 and 19.5,
respectively (Table 1), with statistically significant improvement (p<0.05)
noted over this time per ANOVA statistical analyses.
WWW.CNS.ORG 28WWW.CNS.ORG
28
> Current resident training
does not include a standardized
operative documentation
educational program with
emphasis on coding, which
results in lack of resident
operative documentation and
coding skills after residency
with significant loss of
reimbursement in practice. <
Table 1.
Operative Notes
(60 notes)
Reviewer 1 Reviewer
Errors
2 Errors
Median
Errors
Before Course (30)
32
31
30
After Course (30)
19
20
19.5
Stats (ANOVA)
P<0.05
P<0.05
P<0.05
DISCUSSION
Current American training programs emphasize the six ACGME core competencies, with programs’ ability to foster these requirements affecting
accreditation and subspecialty residency certification. There is growing
uncertainty about the business and practice management aspect as
graduating residents enter medical practice.5 Breitwieser et al. surveyed
717 graduating family medicine residents and identified that 87% had
no medical school lectures or seminars in the business of medicine.2
Over 66% of these residents felt unprepared in medical business management.2 Ridky and Bennett noted that 70% of past general surgery
residents at eight academic centers felt unprepared in practice management.3 A telephone survey of 117 academic centers showed that only
4% of surgery programs offered a formal course in practice management.3 Fakhry et al. noted that 85% of surgery residents believed they
were at a novice level in coding and billing5, with 97% of these residents
feeling this knowledge to be crucial for practice.4
This issue is not as benign as once thought, as Medicare, Medicaid
and other auditing facilities are increasingly scrutinizing both academic
and private practice programs for errors in documentation and coding.1
Jones et al. showed the positive effects of coding education on resident practices in an outpatient clinic through a series of ten lectures
WWW.CNS.ORG focusing on coding requirements, after which residents met with the
coding team and program director.1 Resident response was favorable
and coding compliance increased from 36% to 88 %1 over two years.
The program director in the process also increased his accuracy from
50% to 90% during this time.1
According to the LEAN criteria, by enhancing resident education in
operative documentation and coding, operative notes were dictated
more accurately. While we have not done a cost analysis on this project, a more accurate operative document will likely result in improved
billing. Coding teams, including ours, are often not in the medical field,
and omission of a particular procedure done in addition to the major
procedure harms billing. More accurate dictation enhances monetary
compensation for the hospital and program.
These studies, together with our own, truly demonstrate that these
educational programs are beneficial. Simply coding and dictating a note
may initially be looked upon as simple, but in reality, it can be quite
complex. It is reassuring that it only takes a formal standardized education course to convey this knowledge successfully in a high-volume
inpatient neurosurgery hospital. More multi-center studies focusing on
educational courses in a variety of different aspects of medical care
need to be done across trainees at all levels.
Limitations of our study were that only one resident was followed and
studied and we did not examine the improved financial compensation
for the hospital and program that resulted. Nevertheless, this pilot study
was eye-opening and should be implemented in modern residency training programs.
CONCLUSION
Utilization of our neurosurgery faculty and coder in teaching monthly
coding courses with resident involvement was shown to improve resident operative documentation practices and satisfy ACGME required
systems-based practice and practice-based learning strategies in residency curriculum. Including this format in residency program is recommended and should be expanded to include education in writing daily
notes, history and physicals, clinic notes, and consultations. <
REFERENCES
1
Jones K, Lebron R, Mangram A, Dunn E. Practice management education during surgical
residency. The American Journal of Surgery. 196: 878-882, 2008.
2
Breitwieser D, Adye W, Arvidson M. Resident evaluation of current practice management
training. J Fam Pract. 13: 1063-1064, 1981.
3
Ridky J, Bennett T. Training surgery residents in group practice management. Med Group
Manage J. 38:38-9. 1991.
4
Fakhry S, Robinson L, Henderson K, et al. Surgical residents’ knowledge of
documentation and coding for professional services: an opportunity for a focused
educational offering. Am J Surg. 194: 263-267. 2007.
5
ACGME outcome project: General Competencies for Systems-based practice. Available at
http://www.acgme.org/outcome/comp/compFull.asp#6.
29
MOC: PQRS
Non-Time-Limited Certificate Holders
Participation in regular MOC completing all three-year mini-cycle requirements within three
years. A number of the requirements must be completed during each of the three years (all
of them by the end of the third), or the ABNS will not certify the individual for PQRS.
Time-Limited Certificate Holders
Vincent Traynelis, MD
Director, ABNS
T
he Physician Quality Reporting System
(PQRS) is a federal program with the longterm goal of making more information
about physicians’ performance available to
patients, while rewarding physicians who
provide better care. In 2011 the Centers for
Medicare & Medicaid Services (CMS) added
an MOC option to PQRS. This was done to
encourage physicians to participate in public
quality reporting and improvement through
ABMS Member Boards MOC programs.
Recognizing the additional cost and
administrative burden of doing so, Congress
made available additional financial support for
those who participate in PQRS in combination
with MOC activities.
Physicians who successfully meet the criteria for PQRS reporting in 2013 will receive
an incentive payment equal to 0.5% of their
total estimated Medicare Part B Physician Fee
Schedule allowed charges for covered professional services furnished during the reporting
period. It should be noted that failure to participate in PQRS in 2013 will result in a penalty in
2015. Through MOC:PQRS eligible physicians
who satisfactorily submit data under PQRS
have the opportunity to earn an additional
0.5%. They must participate in a CMS-qualified
All requirements of a three-year mini-cycle must be completed within two years. There are
no exceptions.
MOC program “more frequently” than required
to qualify for or maintain Board Certification
All neurosurgeons may participate in PQRS.
While they may use any approved registry, the
ABMS offers a registry specifically for the purpose. The ABMS has worked with CECity to
develop a suite of tools that can be utilized
separately or as a bundle, depending on the
needs of the neurosurgeon. For instance, a
CMS qualified registry and a Patient Experience of Care Survey are available there. The
data collected is focused on quality measures
for a twelve-month reporting period. The registry will tentatively be open soon and a link
will be posted on the ABNS website once it is
functional.
In addition, ABNS Diplomates are eligible
to participate in the MOC:PQRS incentive. The
first requirement is to participate in PQRS. The
second varies depending on the type of Certificate the Diplomate holds.
Some Diplomates received approval for
MOC:PQRS in 2012. If they have non-time limited Certificates, they must continue on track
in 2013 and 2014. If they have time-limited
Certificates, they must complete the three-year
mini-cycle in 2013 in order to be eligible for
PQRS this year.
ABNS MOC Fees
The creation and maintenance of the MOC
infrastructure is expensive, and there are
administrative costs as well. All Diplomates
participating in MOC must pay the annual dues
of $350, plus the $800 fee for the Cognitive
Examination when it is taken at the end of the
ten-year time frame. If a participant does not
complete a three-year mini-cycle, he or she
may enter a grace period that allows another
six months to finish. The fee is $500 the first
time and $1000 the second; a maximum of
two grace periods may be used per a ten-year
cycle. If The Diplomate exceeds the grace
period or does not participate at all, he or she
must pay a Reinstatement Fee of $2500 to
continue; this may be done once during a tenyear cycle. It is the responsibility of the Diplomate to remain on track to avoid these
penalties. For more information, please visit
www.abns.org. <
30WWW.CNS.ORG
INSIDE THE CNS
WASHINGTON
UPDATE
Katie O. Orrico, JD
Medicare Physician Pay Cuts
Take Effect on April 1, 2013
P
ursuant to the Budget Control Act of 2011
(BCA) (http://1.usa.gov/15euT5s), a two
percent reduction in Medicare payments
to physicians went into effect on April 1, 2013.
While the American Taxpayer Relief Act of 2012
(http://1.usa.gov/UDxOQ7) postponed these
sequestration cuts for three months, Congress
failed to take further action to prevent the cuts
from going into effect. Unless Congress acts,
this two percent pay cut will be implemented
each year, for the next decade. According to the
Centers for Medicare and Medicaid Services
(CMS) (http://go.cms.gov/WxeR42), the claims
payment adjustment will be applied to all claims
after determining coinsurance, any applicable
deductible, and any applicable Medicare
Secondary Payment adjustments.
Questions regarding the sequestration cuts
should be directed to your local Medicare carrier. In the meantime, the AANS and CNS are
hopeful that Congress will take action to eliminate the mandatory payment reductions.
AANS and CNS Send Letter
to Hill Objecting to Cuts for
Stereotactic Radiosurgery
The American Taxpayer Relief Act of 2012
(http://1.usa.gov/UDxOQ7) included a provi-
WWW.CNS.ORG sion equalizing hospital outpatient department payment rates for Cobalt-60 and linear
accelerator-based stereotactic radiosurgery.
Under section 634 of the “fiscal cliff” legislation, payment rates for Cobalt-60-, or Gamma
Knife-based radiosurgery, will arbitrarily be
reduced to equal those of linear acceleratorbased radiosurgery — despite significant cost
differentials between the two technologies.
Overall, the provision will cut hospital reimbursement by $300 million, decreasing the
per-treatment Gamma Knife reimbursement
from approximately $8,100 to $3,400 — a 58
percent reduction. Given that this provision
arbitrarily decreases Medicare reimbursement
for lifesaving treatment for patients with serious brain disorders, including brain tumors,
arteriovenous malformations, pituitary adenomas and trigeminal neuralgia — thereby jeopardizing patient access to this important therapy
— the AANS and CNS sent a letter (http://bit.
ly/16EyKKN) the House and Senate objecting
to these cuts.
AANS/CNS Lead Response to
Washington State on Cervical
Fusion Coverage
Speaking for the AANS, CNS, and other interested neurosurgical and orthopaedic spine
organizations, Joseph Cheng, MD, MS, FAANS,
made a presentation to the Washington State
Health Care Authority’s Health Technology
Clinical Committee (HTCC) on Mar. 22, 2013,
regarding coverage for cervical fusion for
degenerative disc disease (DDD). On Feb. 14,
2013, AANS and CNS submitted a multi-society
letter (http://bit.ly/XW3GPJ) responding to key
issues posed in a draft technical assessment
on the issue. The letter, spearheaded by the
AANS/CNS Rapid Response Team, was signed
by the following organizations: Washington
State Association of Neurological Surgeons,
Washington State Orthopaedic Association,
American Association of Neurological Surgeons, American Association of Orthopaedic
Surgeons, AOSpine North America, Cervical
Spine Research Society, Congress of Neurological Surgeons, AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves, and
North American Spine Society. In the letter, the
groups raise a number of concerns about the
technical assessment, such as the imprecise
definition of DDD, the questionable choice of
papers upon which the report is based, and an
inadequate assessment of the risks of alternatives to fusion.
Neurosurgeons who made significant contributions to this effort included John K. Ratliff,
MD, FAANS; Karin R. Swartz, MD, FAANS;
Matthew J. McGirt, MD; Charles Sansur, MD,
MHSc; and Daniel J. Hoh, MD. More information on the cervical fusion consideration is
available here (http://1.usa.gov/UUSbWo) and
the Mar. 22 meeting materials are available
here (http://1.usa.gov/XhHPrf).
Medicare Patient Empowerment
Act Introduced in the House;
Sign the MPEA Petition
As expected, on March 21, 2013, Rep. Tom
Price, MD (R-GA), introduced H.R. 1310, the
Medicare Patient Empowerment Act (http://1.
usa.gov/10agHqV). This legislation would
permit patients and physicians to privately
contract for Medicare-covered services without penalty to either party. Under current law,
Medicare beneficiaries that choose to see
physicians who do not accept Medicare are
required to pay the physician’s charge entirely
out of personal funds — Medicare does not pay
31
any part of the charge. In addition, physicians
who choose to provide covered services to
Medicare beneficiaries under private contracts
must “opt out” of the Medicare program for
two years, during which time Medicare does
not pay the physician for any covered services
provided to Medicare beneficiaries. These discriminating policies are inappropriate and prevent beneficiaries from seeking care from the
physician of their choice.
Neurosurgeons are highly encouraged to a
take a moment to visit My Medicare-My Choice
(http://bit.ly/16n0pPo), where you can add
your name to a petition supporting the Medicare Patient Empowerment Act.
tronic Health Record (EHR) (http://go.cms.
gov/ZTc8Rs) Incentive Program, the Center
for Medicare and Medicaid Services (CMS)
has decided to delay any Stage 3 meaningful use rulemaking until 2014. In the interim,
CMS is reaching out to stakeholders, through
a request for information (RFI), for advice on
how new payment models affect the implementation of electronic health records. The
AANS and CNS have repeatedly called for a
delay of Stage 3, and plan on responding to
this request for more information to voice neurosurgery’s continued concerns with the EHR
Incentive Program and its associated timelines.
ONC and CMS Delay Stage 3
Meaningful Use Rulemaking
Until 2014
Bipartisan Legislation Aims to
Address U.S. Physician Shortage
by Increasing GME Slots
In an effort to further accelerate and advance
interoperability and health information
exchange beyond what is currently being done
through the Office of the National Coordinator (ONC) (http://bit.ly/Z80nEx) and the Elec-
On March 14, 2013, legislation was introduced in the U.S. Senate and House of Representatives to address the U.S. physician
shortage. In the House two bills were introduced. Reps. Joe Crowley (D-NY) and Michael
Grimm (R-NY) introduced H.R. 1180, the Resident Physicians Shortage Act of 2013
(http://1.usa.gov/14jIjz7). Reps. Aaron Schock
(R-IL) and Allyson Schwartz (D-PA) introduced
H.R. 1201, the Training Tomorrow’s Doctors
Today Act (http://1.usa.gov/16g4uVu). In the
Senate, Sens. Bill Nelson (D-FL), Charles
Schumer (D-NY) and Harry Reid (D-NV) introduced S. 577, the Resident Physicians Shortage Act of 2013 (http://1.usa.gov/YDEcqN).
Both bills will help to ensure that there is an
adequate physician workforce to meet the
health needs of the American population. Specifically, this legislation would provide an
increase of 15,000 new Medicare-supported
graduate medical education (GME) slots
across the country at a rate of 3,000 per year
over five years. One-half of these slots are
required to be used for shortage specialty residency programs, of which neurosurgery qualifies. The AANS and CNS support all three bills,
and joining with the Alliance of Specialty Medicine, sent letters (http://bit.ly/11YqLof) to the
cosponsors endorsing the legislation. <
The CNS is pleased to congratulate
the recipients of the NINDS-funded
Neurosurgery K12 Program,
“Transitioning Early Career Neurosurgeons
to Scientific Independence”.
Sameer Sheth, MD, PhD
Columbia University,
Chair Robert Solomon
Graeme Woodworth, MD
University of Maryland,
Chair Howard Eisenberg
Timothy Lucas, MD, PhD
University of Pennsylvania,
Chair Sean Grady
Additionally, we’d like to congratulate to Dr. Emad Eskandar, Director of the K12 neurosurgery program. More information
on this program can be found at the Neurosurgery Research Career Development Program at http://neurocdp.org.
32WWW.CNS.ORG
IMAGES IN NEUROSURGERY
This patient is a 4 year old male child who presents with progressive lower back
pain, gait imbalance and urinary incontinence. Lumbosacral xray revealed
Currarino triad. MRI revealed an enhancing J-shaped intradural lumbosacral
mass with pelvic extension. Gross total resection achieved via dorsal approach
including lumbosacral laminetomies and non-instrumented laminoplasty.
Pathology was consistent with Anaplastic Ependymoma, WHO grade III. <
Submitted by:
Samer Elbabaa, MD, FAANS, FACS
Department of Neurological Surgery
Saint Louis University School of Medicine
Saint Louis, MO
Figure 1. AP lumbosacral xray demonstrates a sickle sacrum with suggestion of a soft tissue mass displacing the rectum. The finding is suggestive of
Currarino triad.
Figure 2-3. Sagittal T1 with contrast and Coronal T2 MRI of lumbar spine showing a J-shaped intradural lumbosacral mass with pelvic extension via S2 foramen.
WWW.CNS.ORG The CNS Publications represent our global audience.
Here are the number of submissions to Neurosurgery®
from across the globe in 2012!
Country
2012
Country
2012
Country
2012
ALBANIA
1
GREECE
5
POLAND
9
ARGENTINA
1
HONG KONG
4
PORTUGAL
4
AUSTRALIA
18
HUNGARY
1
PUERTO RICO
1
RUSSIAN FEDERATION
2
AUSTRIA
7
INDIA
32
BANGLADESH
2
IRAN, ISLAMIC REPUBLIC OF
9
SAUDI ARABIA
4
BELGIUM
11
IRELAND
1
SERBIA AND MONTENEGRO
3
BRAZIL
24
ISRAEL
8
SINGAPORE
5
CANADA
55
ITALY
68
SLOVENIA
1
CHILE
1
JAPAN
218
SOUTH AFRICA
1
CHINA
144
KOREA, REPUBLIC OF
83
SPAIN
33
COSTA RICA
1
LUXEMBOURG
2
SUDAN
1
CROATIA
1
MALAYSIA
1
SWEDEN
7
CZECH REPUBLIC
2
MEXICO
6
SWITZERLAND
17
DENMARK
5
MOROCCO
2
TAIWAN
28
EGYPT
5
NETHERLANDS
20
FINLAND
9
NEW ZEALAND
2
FRANCE
43
NORWAY
13
GERMANY
97
PAKISTAN
2
Total 1,800
THAILAND
1
TURKEY
31
UNITED KINGDOM
40
UNITED STATES
708